MICHE    LOUTFALLAH 


THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 


PLATE   I. 


EXPLANATION  OF  PLATE  I. 

The  Normal  Fundus. — FIG.  1  represents  the  normal  fundus  of  the  left 
eye  as  seen  in  the  erect  image.  The  oval  is  the  optic  disk  or  optic-nerve 
entrance,  pink  in  color,  and  with  a  white  center,  normally  depressed. 
The  retinal  vessels  emerge  through  it,  the  arteries  lighter  and  yellower, 
the  veins  darker  and  more  crimson  in  color.  Around  the  disk  the  brown, 
irregular  margin  represents  the  choroidal  ring. 

Toward  the  right  of  the  figure  the  darker  red  portion  indicates  the 
appearance  of  the  macula.  The  oval  lighter  ring  represents  the  retinal 
reflex  that  surrounds  the  macula.  It  is  only  seen  by  a  certain  illumina- 
tion, most  frequently  through  the  uudilated  pupil.  The  larger  main 
branches  of  the  retinal  vessels  pass  above  and  below  the  macula,  giving 
off  smaller  branches  that  run  in  toward  it,  but  not  to  its  center.  Each 
of  the  larger  vessels  shows  a  light  streak  along  its  middle.  This  is  com- 
monly most  marked  on  the  arteries.  The  color  of  the  normal  fundus 
may  vary  greatly  from  that  shown. 

The  part  of  the  fundus  here  represented  (about  10  mm.  on  a  side)  is 
much  more  than  can  be  seen  with  the  ophthalmoscope  at  any  one  time. 
Even  with  the  pupil  fully  dilated,  one  canno't  usually  see  more  at  once 
than  the  disk  and  a  zone  around  it  about  as  wide  as  the  disk  itself.  The 
actual  appearance  is  better  represented  by  covering  the  page  with  a  piece 
of  black  paper  in  which  is  cut  a  circular  opening  3  or  4  centimeters  in 
diameter.  The  appearance  presented  by  astigmatism  may  be  seen  by 
looking  at  this  figure  through  a  strong  convex  cylindrical  lens. 

Albuminuric  Retinitis.— FIG.  2  represents  a  case  of  moderate  albu- 
minuric  retinitis  of  the  left  eye.  The  optic  disk  is  a  dirty  red,  and  its 
central  depression  is  quite  obliterated.  Changes  in  the  walls  of  one  of  the 
arteries  passing  upward  have  rendered  them  entirely  opaque  and  white 
for  a  space.  Isolated  white  spots,  due  to  fatty  degeneration,  are  scat- 
tered throughout  the  retina,  and  at  the  macula  they  are  arranged  in  a 
few  radiating  lines.  Near  the  upper  temporal  vein,  and  also  near  the 
lower,  are  patches  of  lighter  color,  due  to  exudate  into  the  retina. 
These  partly  hide  the  vessels  passing  through  them.  At  the  upper 
margin  of  the  lower  patch  is  a  small  "  flame-shaped "  hemorrhage. 
Other  small  spots  of  dark  red,  representing  retinal  hemorrhage,  are 
scattered  throughout  the  fundus.  The  larger  retinal  veins  are  rather 
dark  and  wavy,  and  some  of  the  smaller  veins  are  decidedly  tortuous 
and  irregularly  dilated. 


EXPLANATION  OF  PLATE  II. 

Normal  Optic  Disks. — FIG.  3  represents  the  optic  disk  of  the  right 
eye  presenting  certain  anomalies.  The  ehoroid  is  more  pigmented  than 
in  Fig.  1.  The  upper  temporal  vein  is  seen  to  divide  upon  the  disk  before 
it  enters  t  lie  nerve-head.  At  the  temporal  left )  side  of  the  disk,  the  cho- 
roidal  ring  is  seen  to  include  a  crescent  of  thin,  irregularly  pigmenti-d 
ehoroid,  which  may  have  been  caused  by  previous  choroidal  irritation 
or  congestion.  In  this  crescent  is  seen  a  choroidal  vessel,  and  from  it 
starts  a  cilioretinal  artery  which  passes  a  little  way  on  the  disk,  then 
turns  upon  itself  to  be  distributed  toward  the  macula. 

FIG.  4  illustrates  a  left  optic  disk  surrounded  by  a  "scleral  ring,"  the 
opening  in  the  ehoroid  being  larger  than  the  optic-nerve  entrance.  It 
also  shows  a  broad  deep  "physiological  cnp."  The  darker  spots  in  the 
floor  of  the  cup  are  the  openings  or  meshes  in  the  lamina  cribrosa.  A 
small  artery  and  a  small  vein  cross  the  floor  of  the  cup  and  climb  its 
temporal  side.  The  lower  margin  of  the  cup  overhangs,  so  that  some  of 
the  retinal  vessels  are  first  seen  at  its  edge. 

FIG.  5  represents  a  somewhat  rare  anomaly  of  the  disk,  a  portion  of 
it  looking  almost  like  the  general  fundus.  In  some  cases  there  is  no 
indication  of  the  true  outline  of  the  concealed  portion  of  the  disk,  which 
looks  as  though  covered  by  ehoroid. 

Abnormal  Optic  Disks. — FIG.  6  illustrates  the  cupping  of  the  optic 
disk  in  glaucoma.  The  depression  extends  to  the  extreme  margin  of  the 
disk,  which  is  surrounded  by  a  white  ring,  the  "halo  atrophy"  of  glau- 
coma. The  sides  of  the  cup  overhang  all  around,  except  outward  (to  the 
right)  and  a  little  downward,  where  one  small  artery  may  be  seen  to 
climb  out  of  the  excavation.  The  floor  of  the  cup  is  quite  gray,  and  the 
meshes  of  the  lamina  are  large  and  very  noticeable. 

FIG.  7  represents  the  optic  disk  of  the  right  eye  at  the  beginning  of 
an  optic  neuritis.  The  disk  is  red  and  slightly  swollen,  and  its  small 
vessels  are  numerous.  The  veins  are  rather  full  and  wavy.  Such  an 
appearance  might  be  caused  by  eye-strain,  but  in  this  case  was  due  to 
brain  tumor. 

FIG.  8  shows  the  appearance  of  the  same  optic  disk,  several  weeks 
later  than  Fig.  7.  The  outlines  of  the  disk  are  entirely  hidden  by  a 
swelling  extending  5  D.  into  the  vitreous.  The  veins  are  dark  and 
swollen;  the  arteries  are  narrowed.  Both  are  very  tortuous  at  the 
disk,  but  the  arteries  in  other  parts  of  the  fundus  we're  straight,  while 
the  veins  were  tortuous  throughout.  A  small  "  (lame-shaped  "  hemor- 
rhage is  shown  at  the  temporal  (left)  margin  of  the  swelling.  The 
vision  in  this  eye  was  still  almost  normal  when  this  sketcli  was  made, 
but  declined  very  rapidly  a  month  later. 

FIG.  !)  represents  a  case  of  "consecutive  optic  atrophy."  The  disk  is 
a  dead-white  or  paper-white— "  white  atrophy."  It  is  devoid  of  small 
vessels.  The  retinal  vessels  are  contracted  and  quite  irregular  in  caliber, 
and  white  lines  along  their  margins  show  thickening  of  1  lie  vess  -1-walls. 
Around  the  disk  is  an  irregular  zone  of  thinned  ehoroid  with  irregular 
pigment-deposits. 

FIG.  10  shows  primary  optic  atrophy  in  a  case  of  locomotor  ataxia. 
The  whole  disk  is  shrunken  and  quite  gray  in  color — "gray  atrophy." 
The  retinal  vessels  are  uniformly  contracted,  but  the  fundus  is  other- 
wise normal. 


PLATE   II. 


A  MANUAL 


DISEASES  OF  THE  EYE 


BY 

EDWARD  JACKSON,  A.  M.,  M.  D. 

Emeritus  Professor  of  Diseases  of  the  Eye  in  the  Philadelphia  Polyclinic; 

Formerly  Chairman  of  Section  on  Ophthalmology  of  the  American 

Medical  Association  ;  Member  of  the  American  Ophthal- 

mological  Society  ;  Fellow  and  Ex-President  of  the 

American  Academy  of  Medicine 


With  J78  Illustrations  and  2  Colored  Plates 


PHILADELPHIA 
W.    B .    SAUNDERS 

925  WALNUT  STREET 
i  900 


COPYRIGHT,  1899 
BY  W.  B.  SAUNDERS 


ELECTROTYPEO  BY  PRESS  OF 

WESTCOTT  fc  THOMSON.   PHILADA,  W.    B.   SAUNDERS.    PHILADA, 


I  do 
PREFACE. 


THIS  book  is  intended  to  meet  the  needs  of  the  general 
practitioner  of  medicine  and  the  beginner  in  ophthal- 
mology. It  is  designed  to  aid  in  the  actual  work  of  deal- 
ing with  disease,  and  therefore  gives  the  place  of  first 
importance  to  the  recognition  and  management  of  the 
conditions  likely  to  be  presented  early  in  practice,  rather 
than  to  the  rarer  diseases  and  more  difficult  operations 
that  may  come  later. 

For  practitioners  in  other  departments  of  medicine  and 
surgery  the  most  important  phase  of  ophthalmology  is 
that  of  the  relations  of  ocular  symptoms  and  lesions  to 
general  diseases.  While  Chapter  XX  is  specifically  de- 
voted to  these  relations,  the  references  it  contains  will,  it 
is  hoped,  put  the  reader  in  touch  with  the  important  re- 
lated facts  to  be  found  in  all  the  preceding  chapters. 

For  the  matter  here  presented  the  writer  acknowledges 
his  large  indebtedness  to  a  host  of  patient  workers  in 
ophthalmic  science  and  art,  although  the  scope  of  this 
book  forbids  any  attempt  to  properly  apportion  their 
credit. 

The  bibliography  at  the  end  of  each  chapter  is  not 
intended  to  be  complete.  It  is  merely  an  attempt  to 
open  a  path  for  the  student  into  the  broader  literature 
of  ophthalmology.  The  references  composing  it  have 
been  selected,  not  on  account  of  their  historical  or  general 
scientific  importance,  but  because  they  were  deemed  most 
widely  accessible,  and  best  opened  up  the  general  litera- 
ture of  the  subject. 

The  student  who  desires  to  search  the  whole  domain  of 
recent  ophthalmic  literature  can  find  the  titles,  for  the 


6  PREFACE. 

years  of  its  publication,  in  the  Index  Medians  ;  and  brief 
abstracts  in  the  "  Systematic  Reports  on  the  Progress  of 
Ophthalmology  "  in  the  Archives  of  Ophthalmology.  Most 
important  communications  are  reproduced  in  abstract  in 
the  Ophthalmic  Review  and  the  Annals  of  Ophthalmology. 
The  most  complete  review  of  the  world's  literature  is 
published  in  German,  in  Nagel's  Jahresbericht  ueber  die 
Leistungen  und  Fortschritte  im  Gebiete  der  Ophthalmologie. 
For  the  relations  of  eye  diseases  to  general  diseases, 
Schmidt-Rimpler's  Erkrankungen  des  Auges  im  Zusam- 
menhang  mit  Andern  Krankheiten  is  the  most  complete 
treatise,  and  furnishes  the  best  bibliographies. 

The  following  general  treatises  and  papers  of  especial 
value,  but  not  belonging  to  any  particular  chapter,  may 
here  be  referred  to : 

American  Text-book  of  Diseases  of  the  Eye,  Ear,  Nose, 
and  Throat,  edited  by  G.  E.  de  Schweinitz  and  B.  A. 
Randall  (referred  to  in  chapter  bibliographies  as  "Amer- 
ican Text-book  "). 

System  of  Diseases  of  the  Eye,  edited  by  W.  F.  Norris 
and  C.  A.  Oliver  (referred  to  in  bibliographies  as  "  Sys- 
tem of  Diseases  of  Eye  "). 

Text-book  of  Ophthalmology,  by  E.  Fuchs,  translated 
by  A.  Duane. 

Diseases  of  the  Eye,  by  Geo.  A.  Berry. 

The  Origin  of  Inflammation,  by  Th.  Leber.  Abstracted 
by  Priestley  Smith,  "  Ophthalmic  Review,"  Nov.,  1891,  to 
Feb.,  1892. 

The  Pathological  Examination  of  the  Eyeball.  C.  D. 
Marshall,  "  Royal  London  Ophthalmic  Hospital  Reports," 
vol.  xiv.  Part  II. 

Method  of  Mounting  Ophthalmic  Specimens.  Priestley 
Smith,  "Ophthalmic  Review,"  Jan.,  1897. 

DENVER,  COLORADO, 
November  1899. 


CONTENTS. 


CHAPTER  I. 

PAGE 

Examination  of  the  Patient;  Case  Records;  Abbrevia= 

tions 17 

THE  STUDY  OF  THE  CASE,  17 — Case  History,  17 — Inspection  of 
the  Eyes,  17 — Family  History,  18 — Special  Examination,  18 — Ap- 
proximate or  Provisional  Diagnosis,  19 — Case  Records,  20 — 
Sketches  and  Diagrams,  21 — Field  of  Vision,  23 — Abbreviations, 
23. 

CHAPTER  II. 

Acuteness  of  Vision ;   Field  of  Vision ;  Subjective  Phe- 
nomena ;  Color  Blindness 25 

ACUTENESS  OF  VISION,  25 — Test-objects,  26 — Five  minute  angle, 
27— Cards  of  Test-letters,  28— Illumination,  29— Fingers,  29— 
Other  Tests,  29 — IMPAIRMENT  OF  VISION,  30 — Pin-hole  Disk,  31 
—Loss  of  Sight  in  One  Eye,  32— THE  FIELD  OF  VISION,  33— The 
Perimeter,  34— Taking  the  Field  of  Vision  with  the  Hand,  36— 
Hemianopsia,  36 — Sector-like  Defects  of  the  Field  of  Vision,  38 — 
Scotoma,  39 — Narrowing  of  the  Field  of  Vision,  41 — Inconstant 
Impairment  of  Vision,  41 — Temporary  Hemianopsia,  42 — Incon- 
stant Narrowing  of  the  Field  of  Vision,  42 — Muscse  Volitantes,  42 
— Shadows  of  Retinal  Vessels,  53 — Circulation  of  Blood  in  Retinal 
Vessels,  43— SUBJECTIVE  VISUAL,  SENSATIONS,  44 — Flashes  of 
Light,  45 — Visual  Sensations  of  Ophthalmic  Migraine,  45 — Dis- 
tortion of  a  Point  of  Light,  45 — Rings  of  Light,  46— -Multiple 
Images,  Diplopia,  46 — COLOR  VISION,  47 — Color  Fields,  47 — Color 
Blindness,  48 — PAIN,  51 — Smarting  and  Burning,  the  Feeling  of  a 
Foreign  Body,  51 — Stinging,  52 — Aching,  52 — Neuralgic  Pain,  52 
— Fulness  or  Discomfort  of  the  Eyes,  53 — Aching  outside  the  Eyes, 
53  -Headache,  53 — Loss  of  Sensibility  to  Touch,  54 — Absence  of 
Pain,  54 — BIBLIOGRAPHY,  54. 

CHAPTER  III. 

External  Examination  of  the  Eye ;  Oblique  Illumination  ; 
The  Pupil 55 

EXAMINATION  OF  THE  LIDS,  55 — The  Lashes,  56 — Movements 
of  the  Lids,  56 — Motility  of  the  Eyeballs,  51 — Eversion  of  the 

7 


8  CONTENTS. 

PAGE 

Lids,  57 — HYPEREMIA,  60 — Lid-margins,  60 — Hyperemia  of  the 
Conjunctiva,  60 — Pericorneal  Redness,  61 — Deep  Hyperemia  of  the 
Sclera,  62 — Enlargement  of  the  Scleral  Veins,  63 — Mixed  Forms 
of  Hyperemia,  63 — SWELLING,  63 — Swelling  of  the  Lids,  64 — 
Exophthalmos,  65 — Swelling  of  the  Conjunctiva,  65 — CONJUNC- 
TIVAL  DISCHARGE,  66 — Microscopic  Examination,  67 — OBLIQUE 
OR  FOCAL  ILLUMINATION,  68 — The  Magnifier,  68 — Opacities  of 
the  Cornea,  70 — Reflections  from  the  Surface  of  the  Cornea,  70 — 
Inspection  of  the  Iris,  71— THE  PUPIL,  71— Size  of  the  Pupil,  72 
•  — Pupillary  Reactions,  72 — Reactions  to  Light,  73 — General  Re- 
actions of  the  Pupil,  75 — BIBLIOGRAPHY,  77. 

CHAPTER  IV. 

Ophthalmoscopic  Diagnosis 78 

THE  OPHTHALMOSCOPE,  78 — Methods  of  Using  the  Ophthal- 
moscope, 80 — OPACITIES  IN  THE  MEDIA,  81 — EXAMINATION  OP 
THE  EYE-GROUND,  84 — The  Optic  Disk,  84 — The  Retinal  Vessels, 
86— Color  of  the  Fundus,  87— The  Details  of  the  Choroid,  87— 
Region  of  the  Macula,  88 — Retinal  Reflections,  89 — NORMAL  AP- 
PEARANCES AND  ANOMALIES  OF  THE  RETINA,  90 — Haziness  in 
the  Retina,  90 — Hemorrhage,  90 — Fatty  Degeneration,  91 — 
Medullated  Nerve-fibers,  91 — Changes  in  the  Retinal  Vessels,  92 — 
CHANGES  IN  THE  OPTIC  DISK,  93 — Redness,  93 — Opacity 
of  the  Nerve-head,  94 — Swelling  of  the  Disk,  95— Pallor 
of  the  Optic  Disk,  96 — Cupping  of  the  Disk,  97 — Anomalies  of  the 
Optic  Nerve,  98 — PIGMENTATION,  99 — Pigmentation  of  Optic 
Nerve,  99 — Pigment-deposits  in  the  General  Fundus,  99 — Pigment- 
deposits  in  the  Retina,  99 — Choroidal  Pigment-changes,  100 — Pig- 
ment-blotches at  the  Macula,  101 — CHOROIDAL  EXUDATE  AND 
CHOROIDAL  ATROPHY,  101 — The  Myopic  Crescent,  102 — Other 
Local  Lesions,  102 — BIBLIOGRAPHY  103. 

CHAPTER    V. 

Refraction  ;  Prisms  and  Lenses,  and  their  Strength  and 
Numbering 103 

REFRACTION  OF  LIGHT,  104 — Dioptric  Media,  105 — Index 
of  Refraction,  105 — PRISMS,  110 — Numbering  of  Prisms,  111 — 
LENSES,  112 — Varieties  of  Lenses,  114 — Strength  of  Lenses,  115 — 
Numbering  of  Lenses,  116 — The  Trial  Set,  119 — BIBLIOGRAPHY, 
121. 

CHAPTER  VI. 

Refraction  of  the  Eye ;  Mydriatics  and  Myotics  ;  the  Re- 
fraction Ophthalmoscope  ;  Skiascopy 121 

Assorting  of  Light,  121 — Refraction  of  the  Eye,  123 — Accom- 
modation, 124 — MYDRIATICS  OR  CYCLOPLEGICS  AND  MYOTICS, 
127 — Mydriatics,  127 — Myotics,  129 — OPTICAL  THEORY  OF  THE 


CONTENTS.  9 

PAGE 

OPHTHALMOSCOPE,  130 — DIRECT  METHOD  FOR  THE  MEASURE- 
MENT OP  REFRACTION,  131 — Emmetropia,  131 — Hyperopia,  131 
— Myopia,  133 — SKIASCOPY,  134 — Myopia,  134 — Details  of  the 
Test,  135 — Hyperopia,  139 — Emmetropia,  139 — Appearance  of  the 
Light  in  the  Pupil,  140 — Practical  Applications  of  the  Test,  141 
— INDIRECT  METHOD  OF  OPHTHALMOSCOPIC  EXAMINATION,  142 
— BIBLIOGRAPHY,  143. 

CHAPTER  VII. 

Errors  of   Refraction,  Cylindrical   Lenses,  Presbyopia, 

and  the  Wearing  of  Glasses 144 

PRESBYOPIA,  144— Symptoms,  144 — Diagnosis,  145 — Treatment, 
145 — Prognosis,  147 — HYPEROPIA,  147 — Causes,  149 — Varieties, 
149 — Symptoms,  150 — Diagnosis,  152 — Treatment,  153 — Prognosis, 
154— MYOPIA,  155 — Causes  and  Course,  156 — Varieties,  158 — 
Symptoms,  158 — Diagnosis,  162 — Treatment,  163 — Prognosis,  166 
— ASTIGMATISM  AND  CYLINDRICAL  LENSES,  167 — Cylindrical 
Lens,  167 — Regular  Astigmatism,  169 — Causes  and  Seat,  172 — 
Varietes,  172— Symptoms,  173— Diagnosis,  174 — The  Ophthalmo- 
meter,  178— Skiascopy,  180— Test-lenses,  183— Treatment,  184— 
Prognosis,  186 — ABERRATION,  186 — IRREGULAR  ASTIGMATISM, 
187 — ANISOMETROPIA,  188 — The  Mounting  and  Wearing  of 
Glasses,  189 — BIBLIOGRAPHY,  190. 

CHAPTER  VIII. 

Disorders  of  the  Ocular  Movements 191 

Ocular  Movements,  192 — THE  METER-ANGLE,  193 — PROJEC- 
TION AND  DIPLOPIA,  194 — Amblyopia  with  Squint,  198 — Causes 
of  Squint,  198 — Diagnosis  of  Squint,  199 — The  Cover-test,  199 — 
Power  of  Moving  Eyes  in  Different  Directions,  200 — Measuring 
of  Amount  of  Squint,  201 — Varieties  of  Squint,  203 — PARALYTIC 
SQUINT,  204 — Causes,  204 — Varieties,  204 — Symptoms,  205 — Diag- 
nosis, 206— Palsies  of  Particular  Muscles,  208— Treatment,  212— 
Prognosis,  214 — CONCOMITANT  SQUINT,  215 — Causes,  215 — Varie- 
ties, 216 — Convergent  Squint,  217 — Divergent  Squint,  218 — Ver- 
tical Squint,  219  —Diagnosis,  219 — Treatment,  221 — Prognosis,  224 
— LATENT  SQUINT,  225 — Varieties,  225 — Causes,  227 — Symptoms, 
227 — Diagnosis,  227 — Maddox  Double  Prism,  229 — Systematic 
Exercise,  233 — Operations,  233 — Prognosis,  234— SPASTIC  SQUINT, 
234 — NYSTAGMUS,  234 — BIBLIOGRAPHY,  235. 

CHAPTER  IX. 

Diseases  of  the  Conjunctiva 237 

Hyperemia,  237 — Acute  Catarrhal  Conjunctivitis,  237 — Exan- 
thematous  Conjunctivitis,  241 — Acute  Contagious  Conjunctivitis, 
241 — Diplobacillus  Conjunctivitidis,  242— Ophthalmia  Nodosa,  243 
— Brief  Recurring  Episcleritis,  243 — Purulent  Conjunctivis,  243 — 


10  CONTENTS. 

PAGE 

Croupous  Conjunctivitis,  250 — Diphtheria  of  the  Conjunctiva,  250 
— Chronic  Membranous  Conjunctivitis,  253 — Chronic  Catarrhal 
Conjunctivitis,  253 — Parinaud's  Conjunctivitis,  255 — Vernal  Con- 
junctivitis, 255 — Follicular  Conjunctivitis,  256 — Trachoma,  256 — 
Phlyctenular  Conjunctivitis,  261 — Pterygium,  265 — Pinguecula, 
267 — Pemphigus,  267 — Xerosis,  268 — Tuberculosis  and  Lupus  of 
the  Conjunctiva,  268 — Syphilis  of  the  Conjunctiva,  268 — Amyloid 
Degeneration,  269 — Symblepharon,  269 — Edema,  270— Emphy- 
sema, 270 — Ecchymosis,  290 — Tumors,  271 — Concretions,  271 — 
Burns,  272 — Discoloration,  273 — Diseases  of  the  Caruncle,  273 — 
BIBLIOGRAPHY,  273. 

CHAPTER  X. 

Diseases  of  the  Cornea  and  Sclera      .       275 

General  Conditions  Regarding  the  Cornea,  275 — CORNEAL 
ULCERS,  276 — Simple  Ulcer  of  the  Cornea,  276 — Suppurating 
Ulcer,  278 — Special  Forms  of  Corneal  Ulcer,  286— Phlyctenular 
Keratitis,  288 — Abscess  of  the  Cornea,  Hypopyon  and  Onyx,  290 
— NON-ULCERATIVE  KERATITIS,  292 — Interstitial  Keratitis,  292 — 
Punctate  Keratitis,  297— Striate  Keratitis,  298— Pannus,  298— 
CORNEAL  OPACITIES,  300 — Causes  and  Varieties,  300 — Symptoms, 
303— Treatment,  303 — PROTRUSIONS  OF  THE  CORNEA,  305 — An- 
terior Staphyloma,  305 — Keratectasia,  309 — Conical  Cornea,  309 — 
Keratoglobus,  310 — Tumors,  311 — Burns  of  the  Cornea,  311 — 
DISEASES  OF  THE  SCLERA,  311 — Scleritis,  311 — Staphyloma  of  the 
Sclera,  313 — Buphthalmos,  313 — Injuries,  313 — BIBLIOGRAPHY, 
313. 

CHAPTER  XL 

Diseases  of  the  Iris,  Ciliary  Body,  and  Choroid  ;  Sympa- 
thetic Ophthalmia  314 

IRITIS  AND  CYCLITIS,  314 — Iritis,  314 — Cyclitis,  324 — SEQUELS 
OF  IRITIS  AND  CYCLITIS,  326 — Myopia,  326— Posterior  Synechiae, 
326— Occlusion  of  the  Pupil,  327— Exclusion  of  the  Pupil,  327— 
Total  Posterior  Synechise,  328 — Atrophy  and  Degeneration  of  the 
Iris,  329 — NEW  GROWTHS  IN  THE  IRIS  AND  CILIARY  BODY,  330 
— Gumma  of  the  Iris  and  Ciliary  Body,  330 — Tuberculosis  of  the 
Iris,  330 — Sarcoma  of  the  Iris  or  Ciliary  Body,  331 — Carcinoma, 
331 — Benign  Tumors,  331 — MOTOR  DISORDERS  OF  THE  IRIS  AND 
CILIARY  MUSCLE,  332 — Myosis,  332 — Cycloplegia,  332 — Spasm 
of  the  Ciliary  Muscle,  333 — SYMPATHETIC  OPHTHALMIA,  333 — 
Sympathetic  Inflammation,  334 — Sympathetic  Irritation,  340 — 
DISEASES  OF  THE  CHOROID,  341— Purulent  Clmmiditis,  341 — 
Plastic  Inflammation  and  Atrophy  of  the  Choroid,  o44 — Choroidal 
Hemorrhage,  349 — Detachment  of  the  Choroid,  349 — Colloid 
Masses,  349— Ossification  of  the  Choroid,  349 — Shrinking  of  the 
Eyeball,  350 — TUMORS  OF  THE  CHOROID,  350 — Sarcoma,  350 — 
Carcinoma  and  adenoma,  353 — ANOMALIES  OF  THE  IRIS  AND 


CONTENTS.  11 

PAGE 

CHOROID,  353 — Anomalies  of  the  Iris,  353 — Anomalies  of  the 
Pupil,  353 — Coloboma  of  the  Choroid,  355 — Albinism,  355 — Minor 
Anomalies  of  Pigmentation,  356 — BIBLIOGRAPHY,  356. 

CHAPTER  XII. 
Diseases  of  the  Retina 357 

Symptoms  of  Retinal  Disease,  357 — RETINITIS,  362 — Simple 
Retinitis,  362 — Purulent  Retinitis,  362 — Leukemic  Retinitis  or 
Neuroretinitis,  363 — Hemorrhagic  Retinitis,  364 — Albuminuric 
Retinitis,  365 — Gouty  Retinitis,  368— Diabetic  Retinitis,  368 — 
Syphilitic  Retinitis  and  Chorioretinitis,  369 — Punctate  Retinitis, 
370 — Striate  Retinitis,  370 — Proliferating  Retinitis,  371 — Circinate 
Retinitis,  371 — Retinitis  from  Excessive  Light,  371 — Pigmentary 
Degeneration,  372 — Amaurotic  Family  Idiocy,  374 — Angioid 
Streaks  in  the  Retina,  374 — Embolism  of  the  Retinal  Artery,  374, 
— Thrombosis  of  the  Retinal  Artery,  376 — Thrombosis  of  the 
Retinal  Veins,  377 — Detachment  of  the  Retina,  377 — Subretinal 
Cysticercus,  380 — Glioma  of  the  Retina,  380 — Anomalies  of  the 
Retina,  381 — BIBLIOGRAPHY,  382. 

CHAPTER  XIII. 

Diseases  of  the  Optic  Nerve,  Visual  Tract  and  Centers ; 

Amblyopias 383 

Hyperemia  of  the  Optic  Nerve-head,  383 — Anemia  of  the  Optic 
Disk,  384 — INFLAMMATIONS  OF  THE  OPTIC  NERVE,  384 — Neuro- 
retinitis, 384 — Optic  Neuritis,  385 — Retrobulbar  Optic  Neuritis, 
391 — ATROPHY  OF  THE  OPTIC  NERVE,  391 — Optic  Nerve  Atrophy, 
391 — OTHER  ORGANIC  CHANGES  IN  THE  OPTIC  NERVE,  396 — 
Hyaline  Bodies  in  the  Nerve-head,  396 — Tumors  of  the  Optic 
Nerve,  396— Coloboma  of  the  Optic  Nerve,  397 — Toxic  AMBLY- 
OPIAS, 397— Tobacco  Amblyopia,  397 — Alcohol  Amblyopia,  399— 
lodoform  Amblyopia,  400 — Bisulphid  of  Carbon  Amblyopia,  400 
— Nitrobenzol  Amblyopia,  400 — Quinin  Amblyopia,  401 — Salicylic 
Acid,  402— Acetanilid,  402— Jamaica  Ginger,  402— Filix  Mas,  402 
— CONGENITAL,  HYSTERICAL,  AND  SIMULATED  AMBLYOPIAS,  402 
— Congenital  Amblyopia,  403— Amblyopia  from  Imperfect  Focus- 
sing, 403 — Congenital  Color  Blindness,  403 — Hysterical  Amblyopia 
and  Simulated  Amblyopia,  403 — BIBLIOGRAPHY,  406. 

CHAPTER  XIV. 

Diseases  of  the  Anterior  Chamber,  Crystalline  Lens  and 
Vitreous  Humor 407 

THE  ANTERIOR  CHAMBEii,,407 — Depth,  407 — Alterations  of  the 
Aqueous  Humor,  407 — Hyphemia,  408 — Infection,  Obstruction, 
Cysts,  408 — DISEASES  OF  THE  CRYSTALLINE  LENS,  408 — Cataract, 
408 — Alterations  of  the  Lens  by  Age,  408 — Senile  Cataract,  409 — 
Juvenile  or  Soft  Cataract,  418 — Partial  Cataract,  419 — Anterior 


12  CONTENTS. 

PAGE 

Polar  Cataract,  419 — Posterior  Polar  Cataract.  420 — Lamellar 
Cataract,  420 — Fusiform  and  Central  Cataract,  421 — Secondary 
Cataract,  421 — Dislocation  of  the  Lens,  424 — Coloboma  of  the 
Lens,  425 — Lenticonus,  426 — Aphakia,  426 — DISEASES  OF  THE 
VITREOUS,  426 — Vitreous  Opacities,  426 — Fluid  Vitreous,  428 — 
Hyalitis,  429 — Hemorrhage  into  the  Vitreous,  429 — Blood-vessels 
in  the  Vitreous,  430 — Detachment  of  the  Vitreous,  430— Par- 
asites in  the  Vitreous,  430 — Persistent  Hyaloid  Artery,  431 — 
BIBLIOGRAPHY,  431 

CHAPTER  XV. 

Disorders  of  Tension  of  the  Eyeball 432 

Normal  Intra-ocular  Currents  and  Pressure,  432 — Testing  of 
Intra-ocular  Tension,  434 — GLAUCOMA,  434 — Primary  Glaucoma, 
435 — Glaucoma  with  Exacerbations,  435 — Simple  Glaucoma,  443 — 
Secondary  Glaucoma,  444 — BIBLIOGRAPHY,  448. 

CHAPTER  XVI. 

Diseases  of  the  Lids,  Lacrimal   Apparatus,  Orbit,  and 

Orbital  Walls 448 

INFLAMMATION  OF  THE  LIDS,  448 — Blepharitis,  449 — Marginal 
Blepharitis,  449 — Stye,  450— Abscess,  450 — Tarsitis,  450— DIS- 
EASES OF  THE  SKIN  OF  THE  LIDS,  451— Eczema,  451 — Fissures  of 
the  External  Canthus,  451 — Toxic  Dermatitis,  451 — Erysipelas, 
452— ;Herpes  Zoster,  452 — Molluscum,  452 — Warts  and  Horn-like 
Growths,  453 — Xanthelasma,  453 — Milium,  453 — Spontaneous 
Gangrene,  453 — Syphilis,  453 — DISEASES  OF  THE  LASHES  AND 
EYEBROWS,  454 — Pediculosis,  454 — Trichiasis ;  Distichiasis,  454 
— DISTORTIONS,  DISPLACEMENTS,  AND  ADHESIONS  OF  THE  LIDS, 
455 — Entropion,  455 — Ectropion,  456 — Lagophthalmus,  456 — 
Blepharospasm,  457 — PtosLs,  457 — Epicanthus,  458 — Blepharo- 
phimosis,  458— Anchyloblepharon,  458 — SWELLINGS  AND  TUMORS 
OF  THE  EYELIDS,  459 — Edema,  459 — Emphysema,  459— Chala- 
zion,  459 — Lipoma,  460 — Fibroma,  460 — Neuroma,  460 — Cysticer- 
cus,  460 — Angioma,  460 — Sarcoma,  461 — Lupus,  461 — Epithe- 
lioma,  461 — Burns,  462 — DISEASES  OF  THE  LACRIMAL  PASSAGES, 
462 — Epiphora,  462 — Closure  of  the  Punetum,  463 — Displacement 
of  the  Punetum,  464 — Obstruction  of  the  Canaliculus*,  464 — Ob- 
struction of  the  Nasal  Duct,  465 — Lacrimal  Abscess,  467 — DISEASES 
OF  THE  LACRIMAL  GLAND,  467 — Inflammation,  467 — Hyper- 
trophy, 468 — Prolapse  or  Dislocation,  468 — Cyst,  4G8 — Tumors, 
468 — DISEASES  OF  THE  ORBIT  AND  ORBITAL  WALLS,  468 — 
Orbital  Cellulitis,  468 — Inflammation  of  the  Oculo-orliital  Fascia, 
470 — Periostitis,  Caries,  and  Necrosis,  470 — Enophthalmos,  471 — 
Exophthalmic  Goiter,  472 — Pulsating  Exophthalmos,  472 — Angio- 
mata,  474 — Dermoid  Cysts  of  the  Orbit,  474 — Other  Cysts,  475 — 
Orbital  Tumors,  475 — Imperfect  Development,  476 — Disease  of 
the  Adjoining  Cavities,  476 — Empyema  of  the  Maxillary  Antrum, 
477 — BIBLIOGRAPHY,  477. 


CONTENTS.  13 

CHAPTER  XVII. 

PAGE 

Mechanical  Injuries  of  the  Eye  and  its  Appendages   ...  479 

CONTUSIONS,  479 — Bruise  of  the  Eyelids,  479 — Fracture  of  the 
Bones  of  the  Orbit,  479 — Dislocation  of  the  Eyeball,  480— Eupture 
of  the  Eyeball,  480— Contusion  of  the  Eyeball,  481— Rupture  of 
the  Iris,  481 — Paralysis  of  the  Iris  Sphincter,  481 — Traumatic  Cy- 
cloplegia,  481 — Hemorrhage  into  the  Vitreous,  482 — Injuries  of 
the  Lens,  482 — Traumatic  Edema  of  the  Retina,  483 — Injuries  of 
the  Choroid,  483 — WOUNDS  WITHOUT  LODGEMENT  OF  FOREIGN 
BODIES,  485 — Wounds  of  the  Lids,  485 — Penetrating  Wounds  of 
the  Orbit,  486 — Wounds  of  the  Conjunctiva,  487 — Wounds  of  the 
Cornea,  487 — Wounds  of  the  Sclera,  488 — Wounds  of  the  Ciliary 
Body,  488 — Wounds  Involving  the  Iris,  488 — Wounds  of  the  Lens, 
489— Wounds  Involving  the  Vitreous,  491— FOREIGN  BODIES  IN 
THE  EYE  AND  ORBIT,  491 — Lids  and  Orbit,  492 — Foreign  Bodies 
in  the  Conjunctiva,  492 — Foreign  Bodies  in  the  Cornea,  493 — 
Foreign  Bodies  in  the  Sclera,  495 — Anterior  Chamber  and  Iris, 
495 — Lens,  496 — Vitreous,  Retina,  and  Choroid,  496— BIBLIO- 
GRAPHY, 499. 

CHAPTER  XVIII. 

Remedies  and  their  Applications 500 

REST,  500— MASSAGE,  501— APPLICATIONS  OP  HEAT  AND  COLD, 
502 — THE  MAKING  OF  APPLICATIONS  TO  THE  CONJUNCTIVA,  504 
— ANTISEPTIC  AND  CLEANSING  SOLUTIONS,  507 — CONJUNCTIVAS 
APPLICATIONS,  509 — DUSTING  POWDERS,  511 — CAUSTICS,  ASTRIN- 
GENTS, AND  IRRITANTS,  511 — OINTMENTS,  513— ANESTHETICS,  514 
— MYDRIATICS,  516 — CYCLOPEGICS,  517 — MYOTICS,  519 — MIS- 
CELLANEOUS SOLUTIONS,  520 — DRUGS  USED  FOR  THEIR  SYSTEMIC 
INFLUENCE,  520— BIBLIOGRAPHY,  522. 

CHAPTER  XIX. 

Common  Ophthalmic  Operations 523 

GENERAL  CONSIDERATIONS,  523 — Preparation  of  Patient,  523 
— Preparation  of  Surgeon,  524 — Preparation  of  the  Instruments, 
524 — Position  and  Illumination,  525 — Retraction  of  the  Lids  and 
Fixation  of  the  Eyeball,  525 — Sponging,  527 — DRESSINGS,  527 — 
HEMOSTASIS,  529 — ABSTRACTION  OF  BLOOD,  529 — OPERATIONS 
UPON  THE  LIDS,  529 — Removal  of  Displaced  Lashes,  529— Entro- 
pion  and  Distichiasis,  531 — Canthotomy,  532 — Canthoplasty,  532 — 
Division  of  the  Upper  Lid,  533 — Union  of  the  Lids,  533 — Ectro- 
pion  Operations,  534 — Plastic  Operations  on  the  Lids,  525 — Epi- 
thelial Grafts,  535 — Ptosis  Operations,  536— Chalazion,  537 — 
OPERATIONS  ON  THE  CONJUNCTIVA,  537 — Pterygium,  537— Sym- 
blepharon,  538 — Epithelial  Grafts,  538 — Trachoma  Operations, 
539 — Peritomy,  539 — OPERATIONS  ON  THE  LACRIMAL  PASSAGES, 
540 — Syringing,  540— Slitting  the  Canaliculus,  540 — Probing  the 
Nasal  Duct,  541 — Lacrimal  Stricture,  542 — Extirpation  of  Lacri- 


14  CONTENTS. 

PAGE 

mal  Sac,  542 — OPERATIONS  ON  THE  EYE-MUSCLES,  543 — Teno- 
toiny,  543— Advancement,  544— OPERATIONS  ON  THE  CORNEA, 
545— Removal  of  Foreign  Bodies,  545 — Curetting  of  the  Cornea, 
546 — Paracentesis,  546— Incision  of  Corneal  Ulcer,  546 — Actual 
Cautery,  547 — Galvano-cautery,  547  —Tattooing  the  Cornea,  548 — 
Excision  of  Anterior  Staphyloma,  548 — OPERATIONS  ON  THE 
SCLERA,  549 — Anterior  Sclerotomy,  549 — Posterior  Sclerotomy, 
549 — OPERATIONS  ON  THE  IRIS,  549 — Iridectomy,  549 — Iridotomy, 
552— Corelysis,  552 — Iridencleisis,  553 — OPERATIONS  ON  THE  LENS 
AND  ITS  CAPSULE,  553 — Simple  Extraction,  553— Extraction  with 
Iridectomy,  557 — Linear  Extraction,  557— Suction-operation,  557 
— Extraction  within  the  Capsule,  557 — Scoop-extraction,  557 — 
WenzeFs  extraction,  557 — Discission,  558 — Capsulotomy,  559— 
Removal  of  Lens  for  High  Myopia,  560— OPERATIONS  ON  THE 
EYEBALL,  560 — Magnet-extraction,  560 — Enucleation  of  the  Eye, 
561 — Evisceration,  564 — Implantation  of  an  Artificial  Vitreous,  565 
— BIBLIOGRAPHY,  565. 

CHAPTER  XX. 

Ocular  Symptoms  and  Lesions  Connected  with  General 

Disease 566 

DISEASES  OF  THE  NERVOUS  SYSTEM,  567 — SYMPTOMS  OFTEN  EX- 
PLAINED BY  OCULAR  EXAMINATIONS,  568— DISEASES  OF  THE  CIR- 
CULATORY SYSTEM  AND  KIDNEYS,  572 — DIATHETIC  DISEASES,  574 
— CHRONIC  INFECTIOUS  DISEASES,  575 — ACUTE  INFECTIOUS  DIS- 
EASES, 577 — CONDITIONS  OF  THE  SEXUAL  ORGANS,  581 — DISEASES 
OF  THE  NOSE,  582 — POISONS,  583— BIBLIOGRAPHY,  583. 


DISEASES  OF  THE  EYE. 


CHAPTER    I. 

EXAMINATION   OF  THE  PATIENT;    CASE   RECORDS; 
ABBREVIATIONS. 


THE   STUDY   OF  THE   CASE. 

THE  study  of  a  case  should  begin  with  an  attentive 
hearing  of  the  case  history,  noting  especially  the  symp- 
toms to  which  chief  importance  is  attached  or  from 
which  relief  is  sought.  This  takes  time,  but  it  is  time 
well  spent.  It  is  the  more  important  because  in  most 
ophthalmic  cases  the  diagnosis  rests  chiefly  on  what  the 
surgeon  discovers  by  special  methods  of  examination ;  and 
on  that  account  the  patient's  view  of  his  case  is  liable  to 
be  neglected  altogether.  An  attentive  hearing  strengthens 
the  patient's  confidence.  Even  the  time  occupied  by  a 
garrulous  patient  in  utterly  insignificant  details  need 
not  be  wasted. 

The  patient  being  seated  facing  the  surgeon,  in  a  good 
light,  the  careful  inspection  of  the  eyes  and  face  can  go 
on  with  the  case  history.  The  attitude  of  the  head  may 
indicate  weakness  in  certain  ocular  muscles ;  a  constant 
frown  may  suggest  eye-strain  ;  unconscious  movements 
to  avoid  the  light  tell  of  photophobia.  The  ocular  move- 
ments are  to  be  noted,  and  the  appearance  and  positions 
of  the  lids  and  the  lashes.  The  brightness  of  the  corneal 
surface,  the  presence  or  absence  of  hyperemia  of  the  globe, 
the  evidence  of  conjunct! val  discharge,  the  existence  and 
extent  of  scars  on  the  eyeball,  lids,  lacrimal  apparatus,  or 
related  parts,  should  claim  attention.  The  color  and 
reaction  of  the  iris,  and  the  form,  size,  and  color  of  the 
pupil  give  evidence  regarding  iutra-ocular  conditions. 

The  case  history  is  to  be  extended  in  all  important 

2  17 


18  EXAMINATION  OF  THE  PATIENT. 

directions  by  questions,  especially  as  to  headache,  nervous 
symptoms,  and  previous  attacks  of  eye  disease  or  general 
illness.  The  patient's  age  is  so  often  an  important  ele- 
ment in  the  case  that  it  should  always  be  ascertained. 
Family  history  is  chiefly  of  value  as  to  the  occurrence 
of  blindness  and  the  age  at  which  it  occurred ;  although 
in  connection  with  optic  neuritis,  or  ocular  affections  due 
to  general  disease,  it  may  be  important  in  other  directions. 
Consanguinity  of  parents  is  sometimes  important ;  and 
race  and  previous  place  of  residence  may  throw  light  on 
some  .cases.  With  women  the  facts  as  to  menstruation 
and  child-bearing  should  be  brought  out. 

The  personal  or  family  history  of  syphilis  is  so  often  of 
primary  importance  that  it  should  always  be  in  the  sur- 
geon's mind.  The  direct  question  as  to  previous  syphilis 
is  mostly  worthless  as  to  family  history,  and  often  yields 
nothing  as  to  the  history  of  the  patient.  It  may  be 
sometimes  omitted.  But  the  careful  inquiry  for  evidence 
of  syphilitic  lesions  should  never  be  neglected. 

The  Special  examination  of  a  case  should  generally 
begin  with  tests  of  the  acuteness  of  vision,  with  the  test- 
type  at  four  or  six  meters.  If  the  vision  is  good  enough 
to  make  near  vision  of  small  objects  possible,  the  near 
point  of  distinct  vision  should  be  ascertained.  The  bal- 
ance of  the  ocular  muscles  may  be  tested  with  the 
Maddox  rod.  Next,  the  anterior  segment  of  the  eye 
should  be  carefully  inspected  by  the  oblique  illumination, 
first  with  the  unaided  eye  and  then  through  a  magnifying 
lens,  noting  the  transparency  of  the  cornea  and  crystalline 
lens,  the  smoothness  of  the  corneal  surface,  the  depth  of 
the  anterior  chamber,  and  the  appearance  of  the  pupil  and 
the  iris. 

The  most  important  step  in  the  routine  examination,  to 
be  applied  to  all  eases  in  which  it  is  possible,  is  the 
ophthalmoscopic  examination.  This  should  include  the 
inspection  from  a  distance  to  ascertain  the  transparency 
of  the  media  and  the  general  color  of  the  fundus  reflex, 
the  measurement,  more  or  less  careful,  of  the  refraction  of 
the  retina  or  other  points  to  which  attention  is  directed, 


THE  STUDY  OF  THE  CASE.  19 

and  finally  the  careful  inspection  of  the  details  of  different 
parts  of  the  eye-ground. 

Such  a  routine  examination  will  furnish  the  material 
for  an  approximate  or  provisional  diagnosis,  and 
indicate  the  direction  for  further  investigation.  For 
instance,  if  there  is  reason  to  suspect  lacrimal  disease,  the 
puncta  and  region  of  the  lacrimal  passages  must  be 
minutely  studied.  Pressure  is  to  be  made  over  the 
lacrimal  sac  to  try  if  there  be  any  accumulation  within 
it.  If  there  are  indications  of  conjunctival  disease,  the 
lid  will  be  everted  and  the  conjunctiva  examined.  In 
either  of  these  cases  the  discharge  may  be  studied  micro- 
scopically and  bacteriologically,  and  the  nose  should  be 
carefully  examined  for  causative  or  related  lesions. 

If  there  has  arisen  reason  to  suspect  disorders  affecting 
the  ocular  tension,  this  should  be  tried,  after  the  ophthal- 
moscopic  examination,  by  the  method  detailed  in  Chapter 
XV.  The  tension  should  be  tested  in  all  obscure  cases. 
If  ametropia  be  an  important  factor  in  the  case,  the 
ophthalmoscopic  examination  should  be  supplemented 
by  skiascopy,  the  ophthalmometer  may  be  used,  and  the 
refraction  should  be  tested  with  trial-lenses,  and  if  need- 
ful, a  mydriatic  employed. 

If  the  earlier  examination  has  pointed  to  disease  of 
the  optic  nerve  or  central  nervous  system,  or  to  lesions  of 
the  retina,  the  field  of  vision  is  to  be  taken,  first  for  form 
and  then  for  certain  colors,  green,  red,  and  blue ;  and  the 
condition  of  the  reflexes  and  other  evidences  of  the  state 
of  the  general  nervous  system  are  to  be  investigated. 

Should  the  routine  examination,  especially  that  of  the 
fundus,  reveal  evidence  of  general  disease,  such  as 
Bright's  disease,  diabetes,  severe  anemia,  syphilis,  tuber- 
culosis, etc.,  the  special  examination  must  include  the 
search  for  other  evidences  regarding  such  conditions. 
Certain  examinations  as  to  the  general  conditions,  as  the 
testing  of  the  urine  for  albumin  and  sugar,  should  be 
made  as  a  matter  of  routine  before  undertaking  important 
operations,  such  as  extraction  of  cataract.  Justice  to  the 
patient  requires  a  constant  lookout  for  general  mauifesta- 


20  APPROXIMATE  DIAGNOSIS. 

tions  of  constitutional  diseases  that  may  have  affected  the 
eye,  as  syphilis,  rheumatism,  gout,  or  tuberculosis. 

It  may  be  stated  as  a  general  principle  that  disease  of 
a  tissue  represented  in  the  eye,  especially  if  chronic, 
should  raise  the  inquiry  as  to  the  condition  of  similar 
tissues  in  the  other  organs.  Disease  of  the  skin  of  the 
lids  should  lead  to  the  inquiry  as  to  skin  disease  in  other 
parts  of  the  body.  Conjunctivitis  should  make  the  sur- 
geon consider  the  condition  of  other  mucous  membranes. 
Disease  of  the  retinal  vessels  strongly  suggests  vascular 
disease  elsewhere  throughout  the  body,  as  optic-nerve 
disease  suggests  disease  in  other  parts  of  the  nervous 
system. 

Case  Records. — The  keeping  of  accurate  case  his- 
tories soon  teaches  the  unreliability  of  one's  recollections 
of  symptoms.  In  ophthalmic  practice  the  need  for  case 
records  is  the  greater  because  of  the  wide  variations  that 
occur  in  different  normal  eyes.  An  appearance  that  must 
be  regarded  as  of  no  serious  import  in  the  optic  disk  of 
one  patient  might  be  significant  of  grave  organic  disease 
when  observed  in  the  eye  of  another.  It  is  often  of  great 
importance  to  know  if  a  certain  lesion  be  recent  or  of 
long  standing  ;  and  some  lesions,  such  as  an  opacity  in  the 
cornea,  lens,  or  vitreous,  or  an  atrophy  or  disturbed  pig- 
mentation of  the  choroid,  may  exist  unchanged  for  many 
years,  presenting  such  an  appearance  that  it  is  impossible 
to  judge  from  it  the  age,  and  therefore  the  significance, 
of  the  lesion.  To  know  of  the  previous  existence  or 
non-existence  of  such  conditions,  and  to  know  the  pre- 
vious vision  and  muscular  balance  of  the  eyes,  is  often 
essential  to  a  correct  prognosis  or  a  full  understanding  of 
the  case. 

What  to  record  is  a  serious  question  for  young  sur- 
geons ;  later  a  species  of  selection  occurs,  each  learning 
for  himself  to  select  the  facts  to  be  especially  noted.  It 
wastes  time  and  tends  to  befog  important  points  with 
irrelevant  detail  to  attempt  to  make  each  case  record 
encyclopedic,  but  there  are  certain  things  which  it  is  wise 
to  note  in  every  case. 


CASE  RECORDS.  21 

The  record  should  show  the  name,  sex,  and  age  of  the 
patient ;  and  race  and  nativity  may  have  considerable 
scientific  value.  The  patient's  address  is  important  in  a 
business  way  and  for  the  identification  of  the  case.  The 
occupation  should  be  reported,  so  as  to  show  the  actual 
character  of  the  daily  work ;  thus,  "  house  work,  sews 
three  hours  a  day ;"  "  teacher,  French  and  German, 
written  exercises."  Every  note  made  should  be  dated. 

The  vision  of  each  eye  should  be  noted,  with  any 
circumstance  especially  affecting  it,  as  the  use  of  a  cor- 
recting lens  and  its  strength,  the  name  of  the  mydriatic 
employed,  its  strength,  and  the  time  since  its  instillation. 
If  at  succeeding  visits  vision  is  found  unchanged,  no  note 
regarding  it  is  required.  But  whenever  a  change  in  the 
acuteness  of  vision  occurs,  it  should  be  recorded. 

The  notes  should  include  the  clearness  or  lack  of  clear- 
ness in  the  dioptric  media,  and  the  general  condition  of 
the  eye-ground.  All  decided  anomalies  and  scars  due  to 
former  injury  or  disease  should  be  noted,  so  that  at  a 
subsequent  date  any  marked  departure  from  the  normal, 
not  mentioned  in  the  record,  may  be  presumed  to  have 
occurred  since  the  case  was  last  examined.  Such  a  pre- 
sumption may,  however,  prove  misleading,  unless  great 
care  is  taken  in  the  examination  of  every  case,  and  the 
complete  record  is  made  at  the  time. 

The  record  will  include  such  points  of  personal  and 
,  family  history  as  are  deemed  important.  Generally  it  is 
useless  to  record  a  negative,  unless  the  negative  is  itself 
of  great  significance,  as  the  absence  of  albumin  from  the 
urine  in  a  case  of  apparent,  albuminuric  retinitis.  Besides 
the  chief  clinical  features  of  the  case,  and  all  treatment 
instituted,  it  is  often  well  to  record  also  the  prognosis  or 
the  definite  opinion  given.  It  is  very  embarrassing  to 
have  a  former  opinion  quoted,  often  incorrectly,  against 
one's  self,  with  no  recollection  of  the  real  facts  to  correct 
misapprehensions. 

Sketches  and  diagrams  of  anomalous  or  morbid 
appearances  are  an  extremely  valuable  part  of  case 
records.  They  abbreviate  by  replacing  verbal  descriptions, 


22  SKETCHES  AND  DIAGRAMS. 

and  often  give  a  more  complete  and  exact  record  than  any 
verbal  description  can.  To  facilitate  their  use,  case  books 
have  been  prepared  with  outline  diagrams  of  the  lids,  the 
anterior  segment  of  the  eye,  and  the  fundus ;  also  stamps 
by  which  such  outlines  can  be  reproduced.  These  are 
sometimes  helpful,  but  not  essential.  For  recording 
fundus  lesions  a  plane  ground  of  the  fundus  color,  which 
can  be  rubbed  or  scraped  away  to  white,  and  will  readily 
take  black  and  other  colors,  is  most  helpful.  The 
essential  thing  is  practice  and  familiarity  with  the  making 
of  such  sketches.  A  large  part  of  the  skill  is  in  the 
seeing  of  the  thing  to  be  sketched ;  and  no  one  can  be 
regarded  as  well  trained  in  ophthalmology  who  cannot 
make  such  sketches  as  will  be  valuable  additions  to  his 
case  records. 

In  working  in  black  and  white,  the  lead-pencil  is  more 
manageable  than  pen  and  ink ;  but  additional  effects  can 
be  secured  by  using  both.  For  making  water-color  or  oil 
sketches,  some  little  acquaintance  with  the  laying  and 
combination  of  colors  is  required,  but  not  more  knowledge 
of  color  values  than  is  needed  to  appreciate  the  various 
appearances  presented  by  the  fundus  of  the  eye. 

By  judicious  selection  of  points  to  be  noted,  by  use  of 
abbreviations,  including  those  to  be  mentioned  below,  and 
the  employment  of  sketches,  when  needed,  a  very  good 
case  history  may  be  recorded  in  the  space  commonly 
occupied  by  two  or  three  hundred  words  of  manuscript. 
Such  histories  may  be  written  in  an  ordinary  blank-book, 
one  or  two  cases  to  a  page  ;  and,  if  well  indexed,  this  is 
quite  satisfactory  for  the  ordinary  purposes  of  private 
practice. 

For  the  comparative  study  of  similar  cases,  for  the 
division  of  clinical  work  among  several  workers,  and  for 
hospital  records,  a  card  record  is  superior.  This  may 
be  kept  on  specially  prepared  blanks  in  a  special  form  of 
case,  or  on  ordinary  Manila  cards  kept  in  a  box.  The 
card  record  has  the  advantages  that  it  can  be  written  with 
the  typewriter  and  that  the  individual  card  may  be  small, 
while  for  cases  with  prolonged  histories  any  number  of 


CASE  RECORDS.  23 

cards  may  be  used.  Arrangement  in  alphabetical  order 
renders  the  ordinary  index  unnecessary  ;  but  indexes  may 
be  added,  giving  references  and  cross-references  to  all 
desired  classes  of  cases. 

The  careful  study  of  a  case  presenting  any  marked 
defect  of  the  field  of  vision  will  usually  include  the 
mapping  of  the  field.  The  map  or  diagram  is  preserved 
by  fastening  it  to  the  other  part  of  the  case  record,  or  in 
a  "  field  book,"  with  a  reference  to  the  record.  A  very 
useful  record  of  the  field  of  vision  can,  however,  be  made 
in  this  way  : 

60    55    80 

60    K.    95 

65    75    90 

Normal  field  for  form  for  the  right  eye.  The  letter  in  the  center  tells 
which  eye,  and  the  figures  the  number  of  degrees  the  field  extends  in  the 
different  directions. 

Abbreviations  allow  the  condensation  of  a  case  so 
that  it  will  occupy  less  space,  and  may  be  more  quickly 
looked  over.  Those  given  below  are  in  general  use  or 
have  proven  of  special  service  to  the  writer.  Some  of 
them  are  used  throughout  this  book.  Such  abbreviations 
are  puzzling  when  different  authors  use  similar  abbrevia- 
tions to  indicate  entirely  different  meanings.  Snellen 
used  D.  to  indicate  the  distance  at  which  a  letter  of  any 
given  size  would  subtend  the  angle  of  five  minutes ;  while 
D.  has  come  to  be  universally  understood  as  meaning 
diopters.  Nettleship  used  O.  D.  for  optic  disk,  although 
it  is  very  generally  used  to  mean  oculus  dexter,  the  right 
eye. 

Abbreviations : 

A.  or  Ace.,  Accommodation. 

As.,  Astigmatism,  or  astigmatic. 

Ax.,  Axis  of  cylindrical  lens. 

B.  Base  of  prism. 

O.  or  Cyl.,  Cylinder,  or  cylindrical  lens. 

Cm.,  Centimeter. 

Or.  Centrads. 

D.  Diopter,  or  diopters. 

Emmetropia,  or  eminetropic. 
H.  Hyperopia,  or  hyperopic. 


24  ABBREVIATIONS. 

HI.  or  H.  L.  Hyperopia  latent. 

Hm.  or  H.  M.  Hyperopia  manifest. 

M.  Myopia,  or  myopic. 

M.  a.  Meter  angles. 

mm.,  Millimeters. 

Pp.,  Punctum  proximum,  near  point  of  dis- 

tinct vision. 

Pr. ,  Presbyopia. 

B.  or  B.  E.  or  O.  D.,  The  right  eye.  * 

L.  or  L.  E.  or  O.  S.,    The  left  eye. 
S.  or  Sph..,  Spherical  lens. 

~T~.  Intraocular  tension ;     +~T,    increased 

tension' ;  — ~f",   diminished  ten- 
sion.    (See  Chap.  XV.) 

V.  Vision,  or  acuteness  of  vision. 

Obi.,  Results    of    examination    by    oblique 

illumination. 

Oph.,  Results  of  ophthalmoscopic   examina- 

tion. 

Skia.,  Results  of  skiascopic  examination. 

Mom.,  Results  of  examination  with  ophthal- 

mometer. 

+  Plus,  or  convex. 

—  Minus,  or  concave. 

C:  Combined  with. 

Degrees. 

In  making  records  of  the  balance,  or  lack  of  balance 
of  the  ocular  muscles — records  that  must  be  made  many 
times  and  compared,  to  be  of  much  service — the  following 
are  found  useful : 

Orth.,  Orthophoria,  or  proper  balance  in  all 

directions. 

—  Proper  lateral  balance. 

•<  or  Ex.,  Exophoria,  less  than  normal  conver- 

gence, tendency  to  divergence. 

>  or  Eso.,  Esophoria,  more  than  normal  tendency 

to  convergence. 

||  Vertical  balance. 

V  Bt.  Hyperph.  Right  hyperphoria,  tendency  of  the 

right  eye  to  turn  above  the  left. 

/\  Lt.  Hyperph.  Left  hyperphoria,  or  tendency  of  the 

left  eye  to  turn  above  the  right. 


ACUTENESS   OF   VISION.  25 


CHAPTER  II. 

ACUTENESS  OF  VISION ;  FIELD  OF  VISION ;  SUBJEC- 
TIVE PHENOMENA;  COLOR-BLINDNESS. 

ACUTENESS  OF  VISION. 

NORMAL  vision  requires  focussing  of  light  upon  the 
retina,  and  the  transmission  of  the  nervous  impulses 
caused  by  the  focussed  light,  through  the  optic  nerve  and 
tract,  to  the  normally  related  centers  in  the  brain.  Dis- 
turbance of  any  part  of  this  series  of  actions  causes  impair- 
ment of  the  vision.  The  character  of  the  impairment  often 
indicates  the  seat  of  the  disturbance. 

Acuteness  of  vision  is  tested,  as  the  acuteness  of  touch, 
by  the  ability  to  recognize  the  separateness  of  impressions. 

If  two  points  of  light  make  upon  the  retina  impres- 
sions sufficiently  removed  from  one  another,  they  appear 
as  separate  points ;  but  if  the  impressions  be  brought 
closer  and  closer  together,  there  comes  a  limit  in  the 
power  to  distinguish  between  them,  the  two  fuse  into  one, 
and  the  eye  sees  but  a  single  point  of  light. 

The  distance  the  impressions  must  be  separated  in 
order  to  appear  separate  might  be  measured  upon  the 
retina.  In  Fig.  1,  this  would  be  the  distance  between  a 
and  6,  the  point  on  which  impressions  are  made  by  rays 
from  A  and  B. 


FIG.  1. — The  visual  angle. 


It  is  better  to  indicate  their  separation  by  an  angle 
formed  by  these  rays,  A  a  and  B  b.  These  rays  cross 
at  a  certain  point,  called  the  nodal  point  of  the  eye  (N), 


26  THE   VISUAL  ANGLE. 

and  at  that  point  make  an.  angle  A  N B,  and  its  equal  the 
angle  aNb  (Fig.  1). 

By  testing  many  persons,  it  has  been  found  that  the 
angle  between  the  direction  of  the  two  rays  that  will  give 
separate  impressions  in  a  normal  eye  is  about  one  minute, 
one-sixtieth  of  a  degree.  In  some  healthy  eyes  it  is 
slightly  greater  than  this.  In  others  with  especially  good 
sight,  the  angle  is  notably  less,  but  most  eyes  fairly  con- 
form to  the  standard  of  a  one-minute  angle  as  the  normal 
acuteness  of  vision. 

To  ascertain  the  acuteness  of  vision  of  an  eye, 
we  test  its  visual  angle.  This  might  be  done  by  taking 
two  points  at  a  certain  distance  and  bringing  them 
closer  together  until  they  appeared  as  one,  and  noting  the 
smallest  angle  at  which  they  could  be  seen  as  separated. 
For  convenience,  it  is  better  to  have  a  series  of  points 
separated  by  varying  distances,  and  find  out  which  of 
these  can  be  distinguished  at  a  certain  known  distance 
from  the  eye. 

Test  Objects. — The  simplest  test  object  is  a  group 
of  black  dots  on  a  white  card.  The  person  tested  is 
required  to  tell  the  number  of  dots  in  each  group.  A 
series  of  such  groups,  graduated  so  as  to  be  distinguished 
at  different  distances,  makes  a  test  for  visual  acuteness 
which  is  applicable  to  the  illiterate  and  to  persons  of  all 
nationalities  (Fig.  2). 


•  • 

•• 


mm       •• 

n  c 


FIG.  2.—  Dots  largo  enough  to  be  FIG.  3.  —  Incomplete  square  test  for 

counted  at  live  meters.  full  vision  at  six  meters. 


Another  test,  which  has  the  same  range  of  application, 
is  that  proposed  by  the  writer,  in  which  the  figure  of  an 
incomplete  square  is  used  and  the  deficient  side  turned 
either  up  or  down  or  to  the  right  or  left,  as  shown  here 
(Fig.  3). 

The   patient   is    required    to   designate  which   side   is 


ACUTENESS  OF   VISION.  27 

incomplete,  and  thus  to  show  at  what  distance  the  separate 
arms  are  distinct  from  one  another.  With  normal  acute- 
ness  of  vision,  the  space  between  the  arms  subtends  an 
angle  of  one  minute,  the  whole  figure  subtending  an 
angle  of  three  minutes. 

The  most  generally  popular  and  valuable  tests,  how- 
ever, are  carefully  arranged  series  of  test  letters. 
Snellen,  who  first  put  test  types  on  a  scientific  basis, 
arranged  series  of  letters,  each  of  which  should  have  five 
spaces  in  height  and  five  spaces  in  width,  that  must  be 
seen  in  order  that  the  letter  should  be  distinctly  recog- 
nized. As  each  part  of  the  letter  must  make  its  dis- 
tinct impression  on  the  retina,  the  size  chosen  was  such 
that  the  whole  letter  should  subtend  an  angle  of  five 
minutes,  at  the  distance  at  which  it  was  to  be  seen  by  an 
eye  with  normal  acuteness  of  vision.  This  is  illustrated 
by  the  block  letters  E  and  B  of  Fig.  4,  which  should 
be  recognized  at  a  distance  of  ten  meters. 


FIG.  4. — Snellen  letters  which  subtend  an  angle  of  five  minutes  when  placed 
at  ten  meters. 

To  recognize  fully  each  portion  of  such  a  letter 
requires  about  the  five-minute  angle  that  Snellen  fixed 
upon.  There  are,  however,  many  letters  in  the  alphabet, 
as  O,  L,  T,  and  others,  which  can  be  recognized  without 
seeing  distinctly  five  separate  parts  of  height  or  breadth. 
Hence,  for  many  persons  with  normal  vision,  most  of 
the  letters  of  the  Snellen  scale  are  too  large  ;  and  patients 
frequently  recognize  at  twenty  feet  letters  intended  to  be 
seen  at  ten  or  fifteen  feet.  On  many  test  cards,  B  and  S 
are  the  only  letters  requiring  full  normal  vision  for  their 
recognition  at  the  given  distance. 

This  has  led  to  the  employment  of  smaller  letters,  such 


28  TEST  LETTERS. 

as  would  subtend  an  angle  of  four  or  four  and  one-half 
minutes  at  the  required  distance.  But  with  any  test  card 
different  letters  of  uniform  size  will  be  seen  at  different 
distances  or  with  different  degrees  of  distinctness.  This 
makes  the  apparent  acuteness  of  the  vision  depend  some- 
what upon  the  particular  card  employed. 

The  great  practical  advance  made  by  Snellen  was  in 
numbering  his  test  type  by  the  distance  at  which  they 
could  be  read  by  a  normal  eye.  He  thus  enabled  the 
surgeon  to  make  definite  records  of  the  acuteness  of 
vision  suited  for  comparison.  Such  records  are  made  by 
expressing  the  acuteness  of  vision  by  a  fraction,  of  which 
the  denominator  is  the  distance  at  which  the  letters  should 
be  visible,  and  the  numerator  is  the  greatest  distance  at 
which  they  can  be  read.  Thus,  if  letters  which  should 
be  visible  at  forty  feet  can  only  just  be  read  at  twenty 
feet,  the  acuteness  of  vision  is  expressed  by  the  fraction 
£$.  This  distance  may  be  expressed  in  terms  of  any 
unit,  as  feet,  meters,  or  inches.  If  the  six-meter  type 
be  read  at  four  meters,  the  vision  will  be  recorded  as 
£ ,  or  if  the  thirty-inch  type  is  just  made  out  at  eighteen 
inches,  the  record  will  be  ^-fths.  Snellen  used  Roman 
numerals  for  the  denominators,  intending  thus  always  to 
indicate  the  number  of  feet  at  which  the  type  should 
be  read.  Thus  -^  indicated  vision  normal  at  twenty 
feet. 

The  cards  of  test  letters  as  commonly  printed  have 
each  line  marked  with  the  number  of  feet  or  meters,  or 
both,  at  which  it  should  be  visible  to  the  normal  eye. 

Any  test  card  intended  for  use  at  a  certain  distance 
should  have  at  least  one  row  of  letters  upon  it  smaller 
than  can  be  read  by  eyes  with  normal  acuteness  of  vision 
at  that  distance,  to  provide  for  cases  in  which  the  vision 
is  above  the  standard. 

Test  letters  are  used  by  placing  the  patient  at  the 
distance  corresponding  to  a  line  of  letters  upon  the  test 
rani,  commonly  four  or  six  meters  (fifteen  to  twenty  feet). 
He  is  then  requested  to  read  all  the  letters  he  can  at  this 
standard  distance.  When  it  is  impossible  to  read  even 


ACUTENESS  OF  VISION.  29 

the  largest  letter  on  the  test  card  at  the  standard  distance, 
the  vision  is  to  be  tested  by  bringing  the  card  nearer  until 
the  largest  letter  is  made  out.  The  distance  at  which 
this  is  done  will  then  be  the  numerator  for  the  fraction, 
the  distance  at  which  the  letter  should  be  read  being  the 
denominator. 

In  all  use  of  test  letters,  great  care  should  be  taken 
to  secure  a  good  and  uniform  illumination.  Any 
deficiency  or  variability  in  the  brightness  of  the  illumi- 
nation will  vitiate  the  results  of  such  tests.  The  card 
can  be  exposed  to  the  light  from  an  area  of  unobstructed 
sky.  This  will  be  sufficient  during  the  brighter  portions 
of  fair  days.  But  to  secure  constant  illumination,  it  is 
better  to  employ  artificial  light,  which  should  be  as  bright 
as  that  of  a  good  Argand  burner,  placed  within  twelve 
inches  of  the  card. 

Counting  Fing-ers. — When  it  is  impossible  to  read  even 
the  largest  letters  at  a  distance  of  a  foot,  the  acuteness 
of  vision  is  to  be  tested  by  holding  up  the  fingers  against 
a  dark  background  and  requiring  the  patient  to  count 
them.  The  ability  to  do  this  is  recorded  as  "  counts 
fingers  "  at  a  distance  of  so  many  inches.  The  ability  to 
count  fingers  at  a  certain  distance,  requires  slightly  less 
power  of  vision  than  the  reading  of  the  sixty  meters  or 
two  hundred  feet  letters  at  the  same  distance. 

Other  Tests. — When  fingers  cannot  be  counted,  even  a 
very  few  inches  from  the  eyes  the  power  of  vision  is  to  be 
tested  by  moving  the  hand  in  different  directions  and  re- 
quiring the  patient  to  indicate  in  what  direction  it  is  moved. 
The  ability  to  do  this  will  be  recorded  as  "ability  to  see 
moving  objects." 

When  objects  cannot  be  seen,  the  eye  should  be  tested  in  a 
darkened  room  as  to  its  ability  to  recognize  the  direction  of 
a  lamp-flame,  "light-projection,"  and  when  a  lamp-flame  is 
turned  up  or  down,  or  brought  closer  or  carried  farther 
away  from  the  eye,  the  power  of  "  quantitative  perception 
of  light."  Where  these  are  lacking,  the  test  is  to  be  made 
of  concentrating  a  bright  light  upon  the  eye,  and  then  turn- 
ing it  away,  and  leaving  the  eye  in  complete  darkness,  and 


30  TESTS  OF  LIGHT-PERCEPTION. 

requiring  the  patient  to  say  when  the  light  is  thrown  on 
the  eyes  and  when  it  is  removed.  This  tests  the  power 
of  simple  "  light-perception."  In  applying  the  test  for 
light-perception  in  one  eye,  care  must  be  taken  to  have 
the  other  thoroughly  covered  with  some  opaque  object; 
simply  closing  the  lids  does  not  answer,  because  light- 
perception  is  quite  possible  through  the  closed  lids  of  a 
sound  eye.  The  power  of  vision  is  to  be  tested  for  each 
eye  separately.  (See  page  32.) 

The  accurate  determination  of  the  power  of  vision 
frequently  requires  special  care,  not  to  be  misled  by  state- 
ments of  the  patient.  In  the  reading  of  test  letters,  the 
patient  will  frequently  stop  as  soon  as  the  recognition  of 
the  letters  requires  effort,  and  say  that  he  can  see  no  more. 
Yet,  by  taking  a  little  more  time,  and  coaxing  the  patient 
to  guess  at  one  letter  after  another,  he  can  be  made  to 
read  a  line  or  two  farther  down.  Mistakes  indicate  the 
approach  of  the  limit  of  visual  acuteness  before  it  is 
reached. 

On  the  other  hand,  patients  who  are  absolutely  blind 
often  believe  they  have  considerable  sight.  Their  uncon- 
scious self-deception,  under  the  strong  desire  to  see, 
makes  their  statements  as  to  vision  quite  unreliable. 
Only  such  tests  are  of  value  as  require  them  to  prove 
their  vision,  by  naming  the  number  of  fingers  held  up, 
by  indicating  the  direction  of  movement  of  the  hand,  or 
telling  just  when  the  light  is  made  brighter  or  dimmer. 
Failure  to  determine  exactly  the  power  of  vision  is  more 
likely  to  occur  at  the  first  test  than  subsequently,  and 
any  inaccuracy  about  it  may  render  worthless  important 
conclusions  regarding  the  case. 

IMPAIRMENT  OF  VISION. 

Vision  better  than  £  or  |^  of  the  Snellen  scale,  as  £  or 
M,  may  generally  be  regarded  as  normal.  Vision  that 
falls  below  this  should  be  regarded  as  impaired,  and  the 
cause  of  impairment  should  be  sought  for. 

In  seeking  the  cause  of  impairment  of  vision,  we  must 


IMPAIRMENT  OF  VISION.  31 

first  inquire,  Is  vision  impaired  for  all  distances,  and  at 
all  times  ?  Impairment  of  vision  for  objects  at  one  dis- 
tance, when  objects  at  another  distance  can  be  seen 
perfectly,  can  only  depend  upon  imperfect  adjustment  of 
the  eyes  for  the  distance  at  which  the  vision  is  impaired. 
This  imperfect  adjustment  may  be  due  to  abnormality  of 
the  muscles  that  turn  the  eyes,  but  generally  it  is  due  to 
imperfect  focussing. 

If  a  patient  can  only  read  the  thirty-meter  type  at  four 
meters,  but  can  read  the  quarter-meter  type  at  one-fourth 
of  a  meter,  the  focussing  for  four  meters  is  imperfect,  the 
impairment  of  vision  is  due  to  myopia.  If,  on  the  other 
hand,  distant  objects  are  always  seen  more  clearly,  but 
there  come  times  when  the  patient  is  unable  to  read  fine 
print  or  do  fine  sewing  at  the  ordinary  working  distance, 
this  fact  alone  demonstrates  that  the  power  of  accom- 
modation, the  power  of  focussing  the  eyes  for  near  work, 
is  insufficient  for  the  continuous  demand  made  upon  it. 
If  impairment  of  vision  exists  for  all  distances,  but 
greater  at  one  distance  than  another,  the  difference  is  due 
to  imperfect  focussing. 

If  the  impairment  of  vision  be  equal  for  all  distances, 
it  may  still  be  due  to  imperfect  focussing.  This  can  be 
determined  by  using  the  pin-hole  disk  of  the  trial  set, 
or,  making  a  pin-hole  in  cardboard,  and  holding  it 
before  the  eye.  Looking  through  such  a  minute  opening, 
the  vision  is  always  improved  if  its  defect  is  due  to 
imperfect  focussing,  which  can  thus  be  differentiated  from 
impaired  vision  due  to  any  other  cause. 

When  the  impairment  of  vision  affects  object^  equally 
at  all  distances,  but  is  inconstant,  it  usually  depends 
on  some  serious  derangement  of  the  nervous  apparatus  of 
vision,  the  optic  nerves,  tracts,  or  centers.  AVhen  the 
impairment  is  constant,  and  looking  through  the  pin-hole 
does  not  improve  it,  it  probably  depends  upon  organic 
changes,  which  may  be  either  within  the  eyeball,  where 
they  will  be  visible ;  or  in  the  deeper  structures  where, 
perhaps,  no  other  direct  evidence  of  their  existence  may 
be  obtained. 


32  IMPAIRMENT  OF  VISION. 

I/OSS  of  Sight  in  One  Eye. — In  testing  the  power 
of  vision,  each  eye  is  to  be  tested  separately,  care  being 
taken  to  effectually  cover  the  other  eye  without  making 
any  pressure  upon  it.  Pressure  on  the  eyeball  diminishes 
the  power  of  sight  for  the  time ;  and  having  subjected 
one  eye  to  pressure  while  testing  the  other,  we  should 
not  get  its  full  acuteness  of  vision  upon  testing  it.  It  is 
better  to  hold  something  in  front  of  the  eye  to  be  ex- 
cluded, than  to  permit  the  patient  to  hold  it  closed  while 
he  looks  with  the  other.  The  act  of  holding  one  eye 
closed  while  the  other  is  open,  often  requires  excessive 
pressure  of  the  lids  of  the  closed  eye. 

Impairment  of  vision  affecting  only  one  eye  arises  from 
disease  in  front  of  the  optic  chiasm,  in  the  optic  nerve  or 

the  eye  itself.  Fig.  5  illustrates 
the  course  of  the  nerve  fibers 
and  the  connections  of  the  nerve 
centers  concerned  in  the  act  of 
vision.  The  fibers  coming  from 
the  retina  of  one  eye  pass  back 
through  the  optic  nerve  until 
they  reach  the  chiasm,  and  there 
separate  into  two  sets  that  do 
FIG.  5.— Relation  of  the  optic  not  again  come  together.  Those 

tracts  to  the  fields  of  vision.  p-~,  j-U«  i~r  „„!  U^I-P  ~P  4-K~ 
Semidecussation at  the  chiasm.  irom  the  temporal  halt  OI  the 

retina  are  associated  with  fibers 

from  the  nasal  half  of  the  retina  of  the  other  eye  ;  and  those 
from  the  nasal  half  of  the  retina  are  associated  with  fibers 
from  the  temporal  half  of  the  retina  of  the  other  eye.  Hence, 
any  lesion  interrupting  them  back  of  the  chiasm  will  pro- 
duce impairment  of  the  vision  in  both  eyes,  and  not 
interference  of  one  alone.  Gowers,  however,  believes 
that  in  each  half  of  the  cerebral  cortex  there  is  a  higher 
center  concerned  only  with  the  eye  of  the  opposite  side, 
and  that  disturbance  of  this  center  causes  a  crossed  blind- 
ness of  one  eye.  Cases  of  that  kind  rarely,  if  ever,  reach 
the  ophthalmologist. 


THE  FIELD   OF   VISION. 
THE   FIELD  OF  VISION. 


33 


The  form  of  the  normal  field  of  vision  is  shown  in 
Fig.  6.  R.  is  a  diagram  of  the  field  for  the  right  eye 
as  commonly  represented.  The  cross  at  the  center 
marks  the  direction  in  which  the  eye  is  looking,  the  point 


60 


30 


2/0 


'330 


FIG.  6.— Chart  of  field  of  vision  of  right  eye.  The  center  of  the  circles  repre- 
sents the  fixation  point,  and  the  small  shaded  area  to  the  right  of  it  the  physi- 
ological blind  spot. 

upon  which  it  is  fixed.  The  small  circle  near  it  indicates 
the  physiological  blind  spot,  corresponding  to  the  entrance 
of  the  optic  nerve.  The  concentric  circles  indicate  each 
ten  degrees  of  departure  from  the  visual  axis. 

To  the  temporal  side,  and  a  little  downward,  the  field 
extends  beyond  ninety  degrees  fro,m  the  visual  axis.  In 
other  directions  it  is  somewhat  limited  by  the  brow,  nose, 
and  cheek,  making  the  normal  field  unsymmetrical  for 
each  eye  alone,  but  symmetrical  as  to  the  median  line, 
when  the  fields  of  both  eyes  are  viewed  together.  The 
two  fields  overlapping  have  a  certain  portion,  common  to 
both,  in  which  alone  binocular  vision  is  possible.  This 
is  shown  in  Fig.  7,  where  the  two  fields  are  super- 


34  THE  NORMAL  FIELD. 

imposed,  the  cross  representing  the  direction  of  fixation 
for  both  eyes. 

The  Perimeter. — The  field  of  vision  may  be  accur- 
ately mapped  out  by  use  of  a  perimeter,  shown  in 
Fig.  8.  This  consists  essentially  of  an  arc  that  can  be 
revolved  about  an  axis  passing  through  its  center,  broad 
enough  and  blackened  to  furnish  a  background  for  the 
test  object.  The  patient's  eye  is  placed  at  the  center  of 
this  arc,  the  chin  rest  and  cheek  rest  being  designed  to 
keep  it  fixed  in  this  position.  The  visual  axis  is  turned 


FIG.  7.— Fields  of  vision  for  the  two  eyes  superimposed.  White  area  the  field 
of  binocular  vision.  The  cross  marks  the  point  of  fixation,  and  the  circles  on 
either  side  the  physiological  blind  spots  of  the  respective  fields. 

in  the  direction  of  the  axis  of  the  instrument  B  by  fixing 
the  gaze  on  a  point  in  that  direction. 

To  use  the  perimeter  the  arc  is  set  in  a  certain 
direction,  and  a  test  object  is  moved  along  the  arc,  and 
the  limit  determined  at  which  it  becomes  invisible.  The 
position  of  the  arc  is  then  changed  and  the  trial  is 
repeated.  This  is  done  until  a  sufficient  number  of  points 
have  been  determined  to  indicate  the  outline  of  the  field. 
The  test  object  mostly  employed  is  a  white  square  one 
centimeter  on  the  side.  If  another  is  used  it  should 
be  especially  noted. 

A  better  method  for  accurately  determining  hemian- 
opsia,  is  to  fix  the  test  object  upon  the  arc  a  certain 
number  of  degrees  from  its  axis  ;  then  to  revolve  the  arc 


THE  FIELD   OF    VISION. 


35 


so 


the  test  object  will  describe  a  circle,  and  have  the 
patient  note  where  upon  this  circle  the  test  object  appears 
and  disappears.  Where  a  perimeter  is  not  obtainable, 
the  field  of  vision  can  be  taken  on  a  blackboard,  or  other 
plane  surface.  A  mark  is  made  for  the  gaze  to  be  fixed 
upon  and  then  the  test  object  (commonly  a  piece  of  chalk) 


FIG.  8.— Registering  perimeter. 

is  moved  to  and  from  this  mark,  and  the  patient  is  required 
to  say  where  it  disappears  from  sight  or  reappears.  At 
these  points  chalk  marks  are  made,  and  by  connecting 
them  an  outline  of  the  field  is  obtained.  The  difficulty 
with  a  blackboard  is  the  plane  surface.  However  large  it 
may  be,  it  cannot  include  portions  of  the  field  of  vision 
which  lie  at  or  near  ninety  degrees  from  the  visual  axis. 


36  USE  OF  THE  PERIMETER. 

Records  taken  on  such  a  board  must  always  include 
the  distance  of  the  observer's  eye  from  the  board,  as  well 
as  the  area  of  the  field  of  vision  upon  it. 

Taking  the  field  of  vision  with  the  hand  will 
usually  be  found  most  convenient  and  sufficiently  accu- 
rate in  practical  work.  To  do  this,  the  patient  is 
seated  facing  the  surgeon,  so  that  the  light  shall  fall 
equally  on  both.  If  the  right  eye  is  to  be  tested,  the 
patient  closes  his  left,  and  the  surgeon  his  right  eye, 
and  each  looks  directly  at  the  open  eye  of  the  other. 
While  the  eyes  are  thus  directed,  the  surgeon  carries  his 
hand  to  one  part  of  the  periphery  of  the  field  of  vision. 
He  brings  the  hand  towards  the  visual  axis  in  a  plane 
half  way  between  himself  and  the  patient  until  the  fingers 
are  just  perceptible  to  himself.  Then  moving  the  fingers 
or  holding  them  still,  he  requires  the  patient  to  say  which 
he  is  doing.  This  is  repeated  at  all  parts  of  the  boundary 
of  the  field  of  vision.  If  the  field  be  normal,  the  patient 
answers  correctly  whenever  the  position  of  the  fingers 
is  clear  to  the  surgeon.  If  the  field  be  limited  in  some 
one  direction,  the  patient  in  that  direction  will  require 
the  hand  to  be  brought  closer  to  the  visual  axis  to  recog- 
nize these  movements. 

In  making  this  test,  the  surgeon  superimposes  the 
visual  field  of  one  of  his  eyes  upon  the  visual  field  of  the 
eye  he  is  testing.  A  corresponding  allowance  must,  of 
course,  be  made  for  difference  in  height  of  nose,  or  promi- 
nence of  brow,  or  cheek  ;  and,  at  best,  the  test  is  only  to 
be  regarded  as  an  approximate  one.  But  it  is  one  that  is 
easily  made  anywhere,  and  it  will  reveal  the  presence  of 
any  such  condition  as  hemianopsia. 

Hemianopsia,  or  half  blindness,  is  the  condition 
where  objects  are  seen  with  distinctness  in  one-half  of  the 
field  of  vision,  while  in  the  other  half  there  is  partial  or 
complete  blindness.  In  hemianopsia,  the  blind  half  of 
the  visual  field  is  commonly  separated  from  the  seeing 
half  by  a  vertical  line.  When  the  right  half  of  the  iield 
is  blind  (the  left  half  of  the  retina),  it  is  called  right 
hemianopsia;  when  the  left  half  is  blind  (the  right 


THE  FIELD   OF  VISION.  37 

half  of  the  retina),  it  is  called  left  hetnianopsia.  If 
the  right  half  of  the  field  for  each  eye  is  blind  (temporal 
field  for  right  eye,  nasal  field  for  left  eye),  it  is  called 
right  homonymous  hetnianopsia.  Where  the  left 
half  of  each  field  is  blind  (nasal  field  of  right  eye,  and 
temporal  field  of  left  eye),  it  is  left  homonymous 
hemianopsia. 

Fig.  9  represents  the  field  of  vision  in  a  case  of  right 
homonymous  hemianopsia. 

Homonymous  hemianopsia  depends   always  on   some 


FIG.  9.— Field  of  vision  in  right  homonymous  hemianopsia,  from  apoplectic 
lesion  involving  left  occipital  lobe. 

lesion  back  of  the  optic  chiasm.  Reference  to  Fig.  5 
will  show  that  it  is  back  of  the  chiasm  that  the  nerve 
fibers  concerned  with  these  portions  of  the  visual  fields 
come  together.  Right  hemianopsia  indicates  a  lesion 
back  of  the  chiasm  in  the  left  optic  tract,  or  in  the  cere- 
brum. Left  hemianopsia  indicates  a  lesion  of  the  right 
tract,  or  cerebrum. 

Occasionally,  bitemporal  hemianopsia  occurs.  In 
this,  the  temporal  half  of  each  field  (corresponding  to  the 
nasal  half  of  each  retina)  is  blind,  indicating  that  the  fibers 
which  cross  at  the  chiasm  are  injured,  while  the  other 
fibers  have  escaped.  This  locates  the  lesion  definitely  at 
the  optic  chiasm.  The  other  forms  described  are : 
Binasal  hemianopsia,  which  might  be  due  to  sym- 
metrical pressure  on  both  tracts  just  opposite  the  chiasm, 
the  crossing  fibers  escaping ;  and  altitlldinal  hem- 
ianopsia, the  loss  of  the  upper  or  lower  half  of  the 
field  of  vision.  The  last,  if  not  due  to  detachment  of 
the  retina,  or  other  lesion  within  the  eye,  may  generally 


38  HEMIANOPSIA. 

be  regarded  as  a  symptom  of  hysteria,  or  as  one  of  the 
hysterical  symptoms,  which  occur  in  connection  with 
organic  disease  of  the  brain,  but  it  might  be  due  to  a 
disease  of  a  limited  portion  of  the  visual  centers. 

In  homonymous  hemianopsia,  the  line  dividing  the 
blind  from  the  seeing  portions  of  the  field  of  vision  is 
not  always  vertical.  Its  apparent  inclination  to  the  right 
or  left  may  be  due  to  an  incorrect  position  of  the  head 
and  eyes  while  taking  the  field.  But  in  most  cases  it 
deviates  towards  the  blind  side  near  the  fixation  point, 
passing  some  five  degrees  or  more  from  it  and  leaving  the 
center  of  the  field  of  vision  unaffected.  This  seems  to 
indicate  that  the  part  of  the  retina  corresponding  to  this 
center  of  the  field  of  vision,  is  supplied  with  fibers  con- 
necting it  with  both  sides  of  the  brain. 

Hemianopsia  may  involve  color-perception  alone,  so 
that  one-half  of  the  field  of  vision  is  simply  color-blind, 
hemichromatopsia ;  or  it  may  amount  only  to  a  loss 
of  ability  to  recognize  form  as  clearly  in  one-half  of  the 
field  of  vision  as  in  the  other.  These  varieties  are  called 
relative  hemianopsia. 

Hemianopsia  from  organic  disease  is  usually  permanent, 
and  is  absolute,  light-perception  being  lost  in  the  affected 
part  of  the  field.  But  transient  relative  hemianopsia  is 
not  rare.  In  hemianopsia,  the  reaction  of  the  pupil  to 
light  thrown  upon  the  blind  portions  of  the  retina  should 
always  be  tested.  Its  significance  is  given  with  the 
reactions  of  the  pupils  (Chapter  III). 

Sector-like  defects  of  the  field  of  vision  are 
essentially  like  hemianopsia,  except  that  less  of  the  field 
is  lost.  They  arc  broad  at  the  margin  of  the  field  with 
an  angle  towards  the  center,  but  generally  leaving  cen- 
tral vision  unaffected.  When  one-quarter  of  the  field  is 
lost,  it  is  called  a  quadrant  defect.  Such  a  defect  may 
be  relative  or  absolute.  It  may  be  due  to  disease  or 
pressure  acting  only  on  certain  portions  of  the  optic  tract, 
or  radiating  fibers ;  or  may  arise  from  disease  of  part 
of  the  visual  cortex. 


THE  FIELD   OF   VISION.  39 

Fig.  10  represents  the  appearance  of  the  field  in  such 
a  case. 

Such  a  defect  should  be  sought  for  when  sudden 
obscure  interference  with  vision  is  complained  of.  The 
patient  does  not  usually  understand  the  nature  of  his 


FIG.  10.— Sector  defect  of  the  field  of  vision  from  gunshot  wound  involving  the 
left  occipital  lobe. 

trouble ;  and,  unless  the  visual  field  is  tested,  the  exist- 
ence of  such  defect  will  escape  observation. 

Scotoma. — A  scotoma  is  an  area  of  partial  or  com- 
plete blindness  lying  within  the  field  of  vision.  The 
patient  may  notice  it  as  a  cloud  obscuring  vision  in  a 
certain  direction,  positive  scotoma  due  to  disease  of 
the  retina ;  or  merely  as  a  space  in  which  objects  are  not 
seen,  negative  scotoma  due  to  conditions  of  the  optic 
nerve,  tract,  or  centers.  The  physiological  blind  spot  is 
an  example  of  the  latter  variety. 

A  scotoma  may  be  either  relative  or  absolute — that  is, 
vision  in  the  part  of  the  retina  corresponding  to  it  may 
be  impaired,  or  entirely  lost.  Scotomas  may  affect  any 
part  of  the  field  of  vision.  Generally  they  occur  in  a 
single  eye,  or,  when  present  in  both,  depend  on  separate 
lesions,  even  when  symmetrically  placed.  They  com- 
monly depend  on  lesions  in  the  eyes  themselves,  or  of  the 
optic  nerve  in  front  of  the  chiasm.  True  scotoma. 
due  to  a  lesion  of  the  retina  or  optic  nerve,  is  fixed  in 
position.  It  is  to  be  distinguished  from  false  SCOtoma, 
and  the  obscuration  of  vision  that  may  arise  from  an 
opacity,  a  small  blood-clot,  or  connective-tissue  formation, 
floating  in  the  vitreous.  A  false  scotoma  changes  its 
position  with  reference  to  the  axis  of  vision,  upon 


40 


SCOTOMA. 


movement  of  the  eye.  It  is  positive  scotoma  that  is 
liable  to  be  confused  with  the  shadow  thrown  by  an 
opacity  in  the  vitreous. 

A  form  of  special  importance  is  central  scotoma  due 
to  disease  of  the  choroid  and  retina  in  the  region  of  the 
macula,  to  toxic  amblyopia,  or  to  a  special  form  of  retro- 
bulbar  neuritis.  Central  scotoma  presents  special  diffi- 
culties in  the  determination  of  its  boundaries,  because  the 
impairment  of  vision  involving  the  fixation  point  pre- 
vents the  patient  from  keeping  his  eye  continually  turned 
in  a  certain  direction  throughout  the  test.  It  is  best 
mapped  out  by  having  the  eye  directed  at  first  to  a  series 
of  concentric  circles  upon  the  black-board  or  a  sheet  of 
paper.  The  large  circles  must  be  seen  outside  of  the 
region  of  the  scotoma,  enabling  the 
patient  to  keep  the  eye  compara- 
tively fixed.  It  is  to  be  noted  at 
what  points  the  inner  circles  are 
obscured.  These  points  being  con- 
nected by  lines  give  a  map  of  the 
scotoma.  This  map  may  be  revised 
by  having  the  patient  fix  his  eye 
upon  it,  and  notice  whether  as  it  is 
moved  from  him  the  outline  drawn 
disappears  within  the  scotoma  all 
at  once.  By  repeated  revisions,  an 
accurate  diagram  of  the  scotoma  is 
thus  obtained.  Figure  11  represents  such  a  diagram. 

In  toxic  amblyopia  there  is  commonly  a  larger  scotoma 
for  colors,  especially  for  red  and  green,  than  for  form  ; 
and  there  may  be  complete  scotoma  for  these  colors  before 
any  scotoma  for  form  appears.  To  test  for  color 
SCOtoma,  make  a  small  opening,  one  centimeter  or  less  in 
diameter,  in  a  large  sheet  of  paper.  Holding  this  two 
feet  from  the  patient's  eye  make  him  ga/e  directly  at  it, 
and  taking  in  the  hand  several  skeins  of  the  wools  of  the 
test  colors,  place  the  hand  behind  the  paper  and  present 
first  one  color  then  another  at  the  opening,  and  require 
the  patient  to  name  the  color  seen.  If  the  patient  is 


Fi«.  11.— Diagram  of  cen- 
tral scotoma  from  tobacco 
amblyopia,  the  actual  si/e 
of  the  absolute  scotoma  at 
one  meter.  . 


THE  FIELD   OF   VISION.  41 

allowed  to  look  away  from  the  opening  so  that  the  impres- 
sion is  made  upon  some  portion,  other  than  that  affected — 
the  center  of  the  retina — the  color  may  be  correctly  named, 
although  at  the  fixation-point  the  color-blindness  is  com- 
plete. 

Ring  SCOtoma  is  a  form  in  which  the  center  of  the 
field  of  vision  and  the  periphery  remain  normal,  or  less 
impaired  than  a  ring-like  area  surrounding  the  center  of 
the  field.  It  may  possibly  be  due  to  a  lesion  affecting  a 
special  portion  of  the  optic  nerves  or  tracts,  but  generally 
it  is  caused  by  disease  in  the  corresponding  portions  of 
the  choroid  and  retina.  Most  frequently,  scotomas  are 
single,  or  arranged  without  symmetry  ;  they  may  be  per- 
manent or  quite  transient.  The  latter  will  be  referred  to 
in  connection  with  transient  impairment  of  vision. 

Narrowing  of  the  field  of  vision  is  the  most 
significant  symptom  of  atrophy  of  the  optic  nerve  and 
certain  allied  affections.  It  is  ascertained  by  testing 
the  field  of  vision  with  the  hand  or  with  a  perimeter. 
Symmetrical  narrowing  points  to  primary  atrophy  of 
the  optic  nerve  or  to  the  effects  of  certain  poisons. 
[See  Quinin  Blindness,  Chapter  XIII.]  It  is  apt 
to  affect  the  field  of  vision  for  colors  before  there  is  any 
notable  change  in  the  field  for  form.  Irregular  nar- 
rowing of  the  field,  which  may  also  affect  the  field  for 
colors  more  than  the  field  for  form,  is  indicative  of  second- 
ary optic  atrophy,  or  injury  to  the  tracts  as  by  .glaucoma, 
optic  neuritis,  etc. 

Inconstant  impairment  of  vision  after  the  eyes 
have  for  some  time  been  used  for  close  work,  occurring 
particularly  in  the  latter  part  of  the  day,  or  when  the 
eyes  are  used  by  artificial  light  in  the  evening,  is  caused 
by  the  sudden  relaxation  of  the  accommodation,  after  the 
ciliary  muscle  has  been  exerted  until  it  is  tired  and  will 
work  no  longer.  It  is  apt  to  occur  in  persons  coming  to 
the  age  when  they  require  glasses  for  near  work,  or  in 
young  persons  who  have  high  hyperopia.  It  may  occur 
in  such  persons  for  a  short  time  after  eating  a  meal. 


42  INCONSTANT  IMPAIRMENT. 

Sudden  brief  blurring  of  the  sight  of  one  eye  may  be 
caused  by  pressure  on  the  eyeball. 

What  is  often  spoken  of  as  a  blurring  of  the  sight  of 
one  eye,  is  temporary  hetnianopsia,  a  blurring  of  one 
half  of  the  field  of  vision,  or  a  sector-like  defect.  It  may 
be  accompanied  with  the  appearance  of  irregular  figures 
and  rays  of  light.  This  symptom  is  due  to  some  dis- 
turbance of  the  visual  tracts  or  visual  centers.  It  com- 
monly lasts  for  a  few  minutes,  and,  as  it  disappears,  is 
followed  by  a  severe  headache,  which  may  be  confined  to 
one  part,  or  may  spread  all  over  the  head.  Frequently 
the  whole  of  the  field  of  vision  is  involved  in  such  an 
obscuration.  The  attacks  occur  at  irregular  intervals, 
sometimes  quite  frequently,  for  years. 

Temporary  scotomas  may  be  caused  by  the  exhaus- 
tion of  the  retina  from  gazing  so  that  a  bright  light  will 
fall  continuously  on  some  one  part  of  it.  Such  a  scotoma 
is  noticed  after  looking  at  the  sun,  or  an  electric  light. 
It  usually  occupies  the  center  of  the  field  of  vision,  inter- 
fering with  the  perception  of  the  object  looked  at ;  but  it 
may  appear  in  some  other  part  of  the  field.  When  the 
object  gazed  at  has  decided  color,  the  scotoma  may  have 
the  complementary  color.  In  certain  conditions  of  the 
retina  these  scotomas  may  be  made  to  change  color  by 
changes  in  the  general  illumination  of  the  retina,  or  by 
pressure  on  the  eyeball. 

Inconstant  narrowing1  of  the  field  of  vision, 
particularly  diminution  of  the  field  while  being  tested, 
is  indicative  of  hysteria  or  neurasthenia. 

Muscae  volitantes  (named  for  their  fancied  resem- 
blance to  running  mice)  are  shadows  cast  upon  the  retina 
by  specks  in  the  vitreous  humor.  Such  shadows  are 
chiefly  noticed  by  myopic  eyes.  But  something  of  the 
kind  may  be  brought  out  in  any  eye  by  entoptic  observa- 
tion ;  that  is,  by  looking  through  a  small  pin-hole  held 
one-half  inch  before  the  eye  with  a  uniformly  illuminated 
background,  or  by  looking  through  a  microscope  with  the 
field  illuminated  but  unoccupied  by  any  distinguishable 
object.  Such  shadows  move  with  the  specks  causing  them, 


THE  FIELD   OF    VISION.  43 

when  the  eyes  move ;  but  do  not  preserve  a  constant 
relation  to  the  visual  axis  or  the  point  looked- at.  When 
the  eye  ceases  to  move  they  do  not  at  once  come  to  rest, 
but  gradually  settle  up  or  down  across  the  field  of  vision, 
until  they  reach  the  position  of  rest.  The  smaller  and 
more  delicate  of  these  shadows  have  generally  the  shape 
of  dots  which  may  be  arranged  in  strings,  or  of  threads. 
The  larger  ones  may  assume  any  shape.  The  patient 
often  becomes  familiar  with  the  shape  of  each  and  can 
promptly  recognize  it.  The  depth  of  such  specks  may 
be  measured  by  using  two  pin-holes  about  half  the  width 
of  the  pupil  apart.  With  these  two  overlapping  lumin- 
ous circles  are  seen,  and  in  the  overlapping  portion  the 
shadows  are  seen  double.  The  distance  between  the 
double  images  is  to  the  distance  between  the  centers  of 
the  two  circles,  as  is  the  distance  of  the  speck  in  front 
of  the  retina,  to  the  distance  of  the  pupil  in  front  of  the 
retina,  about  1 8  mm. 

The  shadows  of  the  retinal  vessels  may  be  rendered 
visible  in  the  dark  room  by  sitting  in  the  position 
for  oblique  illumination  of  the  eye,  turning  the  eye 
strongly  toward  the  nose,  concentrating  the  light  on  the 
sclera  with  a  convex  lens,  and  then  moving  the  lens 
slightly  up  and  down,  or  back  and  forth.  This  shows 
the  shadows  of  the  larger  trunks  of  the  retinal  vessels, 
except  those  that  pass  to  the  nasal  side,  the  so-called 
figure  of  Purkinje. 

The  figure  of  the  finer  vessels  which  ramify  in  the 
region  of  the  macula  may  be  brought  out  by  looking  at  a 
uniformly  illuminated  background  through  a  pin-hole  held 
close  to  the  eye  and  moved  rather  rapidly  in  a  small  circle 
before  the  pupil.  The  movement  must  be  kept  up  for  a 
minute  or  so,  and  then  a  figure  like  that  of  Fig.  12  slowly 
makes  its  appearance. 

The  circulation  of  the  blood  in  the  retinal  vessels 
may  be  seen  by  looking  at  a  uniform  light  cloud,  or  at 
the  sky,  through  a  rather  dark-blue  glass.  Looking 
steadily  two  or  three  minutes,  small  light  oval  bodies  will 
appear,  moving  rapidly  toward  the  center  of  the  field, 


44  RETINAL  CIRCULATION. 

but  before  reaching  it  turning  and  whirling  away  again. 
These  are  corpuscles  moving  in  the  capillaries,  sometimes 
retarded  and  elongated  in  narrow  portions,  then  regaining 
their  form  and  gliding  rapidly  onward.  They  are  seen  to 
follow  definite  paths,  but  the  walls  of  the  vessels  through 
which  they  pass  are  invisible.  For  certain  intelligent 


FIG.  12.— Arrangement  of  minute  vessels  at  center  of  macula. 

patients,  it  is  possible  to  use  the  entoptic  method,  figures 
of  the  retinal  vessels,  and  the  retinal  circulation  to  study 
minute  intraocular  lesions.  Minute  specks  of  the  vitreous 
opacity  may  be  studied  entoptically,  although  not  percep- 
tible in  any  other  way.  Somewhat  larger  opacities  after 
being  located  in  this  way  may  be  recognized  with  the 
ophthalmoscope. 

SUBJECTIVE  VISUAL  SENSATIONS. 

The  removal  of  an  eye  or  the  complete  blindness  of 
both  eyes  is  not  followed  by  a  continual  sense  of  dark- 
ness;  and,  in  the  absence  of  the  normal  stimulus  to  the 
visual  centers,  vision  memories  may  bo  so  vivid  that  it  is 
difficult  to  convince  the  patient  that  he  does  not  still  see. 
In  some  cases  the  sensations,  particularly  of  flashes  of 
light,  become  quite  annoying.  They  may  indicate 


SUBJECTIVE   VISUAL  SENSATIONS.  45 

mechanical,  circulatory,  or  reflex  excitation  of  the  visual 
centers,  possibly  proceeding  from  the  stump  of  the  optic 
nerve  or  some  portion  of  the  visual  tract,  but  generally 
from  other  sources. 

Flashes  of  I/ight. — These  may  arise  from  excitation 
of  any  part  of  the  visual  tract.  The  most  common  cause 
acting  within  the  eye  and  giving  rise  to  them  is  the  irrita- 
tion or  involvement  of  the  retina,  in  connection  with 
acute  choroidal  inflammation.  Where  this  is  strictly 
localized,  flashes  may  appear  confined  to  a  single  part  of 
the  field  of  vision.  Where  the  attendant  hyperemia  is 
more  general,  the  sensations  will  be  more  widely  dis- 
tributed. They  are  most  evident  in  complete  darkness 
with  the  eyes  closed,  and,  sometimes  can  be  provoked  at 
will  by  pressure  of  the  lids  on  the  globe.  Their  liability 
to  be  affected  by  pressure  upon  the  eyeball  is  the  means 
of  distinguishing  flashes  of  light  due  to  ocular  disease 
from  those  due  to  irritation  of  the  nerve  tracts  or  centers. 

The  abnormal  visual  sensations  of  ophthalmic 
migraine  are  found  by  most  patients  difficult  to  describe, 
yet  the  account  given  of  them  cannot  be  mistaken  for 
anything  else.  They  are  sometimes  compared  to  the 
quivering  of  the  air  over  a  heated  surface ;  sometimes  to 
the  glimmer  of  light  in  the  water;  at  others  to  a  stream 
or  flood  of  water,  proceeding  from  a  particular  part  of  the 
field  of  vision.  Most  frequently  they  are  compared  to 
fire-works ;  and  a  figure  with  re-entering  angles  like  a 
fortification  is  very  often  alluded  to.  In  a  few  cases 
they  take  definite  recognizable  forms,  as  that  of  a  ball  of 
fire,  or  even  a  human  face  or  outline  figure.  Generally 
the  appearances  vary  at  different  stages  of  the  attack, 
passing  away  as  a  cloud  of  luminous  mist,  which  may  be 
the  only  appearance  noticed.  The  feeling  is,  not  that  the 
part  of  the  field  of  vision  is  blind,  but  that  the  real 
objects  in  it  cannot  be  perceived  through  these  subjective 
visual  appearances. 

Distortion  of  a  Point  of  I/ight. — The  conventional 
figure  of  a  star,  a  central  point  surrounded  by  divergent 
rays,  is  based  upon  the  fact  that  a  point  of  light  presents 


46  DISTORTION  OF  A  POINT. 

such  an  appearance  to  a  great  majority  of  eyes.  This 
arises  from  stigmatism  ;  mostly  from  irregular  stigmatism. 
An  eye  free  from  this  defect  sees  a  point  of  light  simply 
as  a  brilliant  dot. 

The  exact  figure  presented  differs  for  each  eye,  as  is 
demonstrated  by  comparing  closely  the  position  and  the 
length  of  the  rays  of  the  right  and  left  eyes  used  sepa- 
rately. It  may  also  be  made  to  vary  by  changes  in 
accommodation.  Any  change  in  such  a  figure  indicates 
a  change  in  the  stigmatism.  This  may  be  dependent 
upon  changes  in  the  cornea,  as  by  corneal  ulcer  or  abra- 
sion, or  in  the  crystalline  lens,  as  before  cataract. 

Rings  of  light  exhibiting  different  colors  of  the  rain- 
bow about  a  point  of  light,  as  a  lamp-flame,  are  usually  a 
symptom  of  glaucoma.  They  may,  however,  arise  apart 
from  glaucoma  through  alterations  in  the  cornea. 

Multiple  Images;  Diplopia. — Monocular  Diplo- 
pia. — When  a  single  object  gives  rise  to  two  or  more 
impressions,  we  must,  by  closing  one  eye,  ascertain 
whether  this  symptom  exists  when  only  one  eye  is  used. 
If  the  diplopia  be  monocular,  it  commonly  depends  on  a 
defect  of  the  refracting  surfaces,  or  media.  It  may 
indicate  a  dislocation  of  the  lens,  so  that  part  of  the  light 
entering  the  eye  passes  through  the  edge  of  the  crystalline 
lens,  while  another  part  passes  alongside  of  it.  Similar 
monocular  diplopia  is  produced  by  looking  through  the 
edge  of  a  spectacle  lens  or  prism.  Or  it  may  arise  from 
great  inequalities  in  the  lens  itself,  and  from  changes 
preceding  cataract,  or  from  the  prismatic  action  of  facets 
in  the  cornea;  from  either  of  these  latter  causes  the 
images  noticed  will  be  irregular  and  imperfect  and  will 
generally  be  of  unequal  distinctness. 

Irregularities  of  the  dioptric  apparatus  sufficient  to 
cause  multiple  images  can  always  be  detected  by  careful 
objective  examination.  Where  no  such  irregularities 
exist  to  account  for  monocular  diplopia,  it  must  be 
regarded  as  due  to  abnormality  of  the  visual  centers.  In 
this  form  the  images  are  commonly  perfectly  definite  and 
regular,  although  not  always  of  equal  intensity.  This 


COLOR   VISION.  47 

variety  of  diplopia  is  probably  in  most  cases  only  pre- 
tended. It  may  occur  in  hysteria,  or  as  one  of  the 
hysteroid  symptoms  of  organic  disease  of  the  brain.  Its 
reality  is  very  difficult  to  determine. 

Binocular  Diplopia. — Double  vision,  the  one  image 
belonging  to  one  eye,  and  the  other  to  the  other  eye, 
always  indicates  that  the  eyes  are  not  both  turned  in  the 
same  direction,  but  that  they  squint.  The  subject  is 
therefore  considered  mainly  in  connection  with  paralyses 
of  the  ocular  muscles  and  squint.  (See  Chapter  VIII.) 

But  while  such  diplopia  cannot  exist  without  squint, 
the  squint  may  be  present  without  diplopia.  Although 
the  eyes  may  be  turned  in  diiferent  directions,  one  may 
not  perceive  any  image  of  the  object  looked  at,  or  the 
image  may  be  so  feeble  as  to  be  disregarded.  In  some 
cases  the  second  image  may  be  noticed  at  times  and  at  other 
times  be  absent ;  and  this  may  mean  either  that  the  squint 
is  temporarily  absent,  or  that  the  second  image  is  for  the 
time  unnoticed.  The  diplopia  is  apt  to  be  persistent  and 
annoying  where  squint  has  occurred  during  adult  life,  if 
vision  remains  good  in  the  squinting  eye. 

COLOR  VISION. 

None  of  the  theories  of  color  perception,  explained 
in  works  on  physiology,  is  fully  established.  They 
are  of  much  theoretic  interest,  but  have  not  sufficient 
bearing  on  ordinary  clinical  ophthalmology  to  justify 
repetition  here. 

Color  perception  is  a  more  delicate  function  of  the 
nervous  apparatus  of  vision  than  the  perception  of  form, 
and  is  more  easily  impaired  or  destroyed  by  disease. 

Color  perception  is  most  vivid  at  the  center  of  the 
macula,  from  which  point  the  retina  becomes  less  sensitive, 
most  rapidly  for  green,  almost  as  rapidly  for  red,  and 
more  slowly  for  blue. 

In  general  shape,  the  color  fields  resemble  the  field 
for  form.  With  the  usual  one-centimeter  square  of  color 
for  a  test  object,  the  fields  are  about  as  shown  in 


48  COLOR  BLINDNESS. 

Fig.  13.  Narrowing  of  the  field  is  to  be  ascertained 
with  colored  tests,  as  impaired  field  for  form  is  studied 
with  a  white  test  object.  Hemichromatopsia  and  color 
scotoma  have  been  referred  to  on  pages  38  and  40. 

The  appearance  of  objects  as  to  color  is  largely  a 
matter  of  contrast.  Colored  vision  is  a  curious  phenom- 
enon, probably  due  to  contrast.  Blue  vision,  kyanopsia,  is 
usually  seen  after  the  extraction  of  senile  cataract.  The 


FIG.  13.— Fields  of  vision  for  colors  of  the  right  eye.  The  dotted  line  shows 
field  for  green,  the  alternate  dots  and  lines  that  for  red,  and  the  broken  line 
for  blue.  The  solid  line  is  the  field  for  form. 

cataract  has  long  given  an  amber  or  brown  tinge  to 
all  the  light  entering  the  eye  through  it ;  and  when  it  is 
removed  the  light  seems  to  have  the  complementary  color, 
blue.  If  the  other  eye  is  still  the  seat  of  cataract,  and 
therefore  continues  to  receive  the  amber  light,  the  con- 
trast may  keep  the  blue  color  noticeable  for  several  weeks. 
But  if  the  other  eye  receives  uncolored  light,  the  blue 
quickly  fades  away. 

Red  vision,  or  erythropxia,  is  noticed  sometimes  after 
cataract  extraction  or  after  exhausting  disease,  but  more 
frequently  after  prolonged  exposure  of  the  eyes  to  bril- 
liant illumination,  as  in  high  mountain  regions  and  upon 
the  Polar  snow-fields. 

Color  Blindness. — Narrowing  of  the  color  fields 
may  extend  to  their  complete  extinguishment.  This  is 


COLOR   VISION.  49 

seen  in  connection  with  severe  diseases  of  the  retina, 
optic  nerves,  or  visual  centers,  and  constitutes  a  variety 
of  color  blindness. 

More  frequently  color  blindness  is  a  congenital  defect 
which  becomes  apparent  when  the  attempt  is  made  to 
discriminate  certain  colors.  In  the  great  mass  of  cases  the 
colors  imperfectly  perceived  are  red  and  green,  this  form  of 
defect  being  known  as  red-green  blindness.  Cases  occur 
in  which  the  complementary  colors,  orange  and  blue,  or 
yellow  and  purple,  are  not  recognized,  but  these  varieties 
of  color  blindness  are  very  rare. 

Something  of  the  effect  of  color  blindness  may  be  pro- 
duced by  viewing  objects  through  colored  glasses.  The 
objects  still  seem  to  have  color,  but  not  their  proper 
colors,  and  the  change  is  most  noticeable  with  regard 
to  the  color  of  the  glass  used  or  its  complementary 
color. 

Congenital  color  blindness  cannot  be  cured  or  overcome 
by  any  course  of  training.  Its  recognition  is  of  impor- 
tance in  connection  with  certain  occupations.  Inability  to 
recognize  red  or  green  may  be  extremely  dangerous  in  a 
pilot  or  raihvay  engineer.  But  on  the  other  hand,  persons 
who  have  imperfect  perception  of  color  learn  to  distin- 
guish objects  by  their  shading,  and  often  excel  in  work 
devoid  of  color  but  requiring  the  exact  appreciation  of 
shading,  as  in  engraving,  or  judging  of  black  goods. 

For  practical  purposes,  the  defect  is  to  be  recognized 
by  the  Holmgren  test  with  colored  wools.  For  this  the  per- 
son to  be  tested  is  given  certain  skeins  of  colored  wools 
called  test-skeins,  and  required  to  select  from  a  pile  of 
miscellaneous  colors,  the  skeins  which  most  nearly  match 
the  test.  The  skeins  from  which  the  selection  is  to  be 
made  include  some  of  the  same  color  as  the  test,  but  of 
lighter  or  darker  shades.  These  are  called  "  match 
skeins."  With  them  are  mixed  skeins  of  what  are 
known  as  "  confusion  colors,"  colors  which  appear  to  the 
normal  eye  entirely  different  from  that  of  the  test  skein, 
yet  are  most  likely  to  be  selected  by  the  color  blind  as 
resembling  it.  The  first  test  is  one  of  very  light  green, 


50  THE  HOLMGREN  TEST. 

to  be  matched  with  skeins  of  the  same  hue ;  and  such 
skeins  the  normal-sighted  will  select  without  hesitation. 
The  color  blind  will,  however,  place  with  this  a  sage 
green,  red,  very  light  brown,  or  gray.  With  these  may 
also  be  placed  some  of  the  match  skeins.  Or  the  person 
tested,  while  not  actually  placing  the  confusion  colors 
with  the  test,  may  pick  them  up  and  consider  them  as 
closely  resembling  it.  Some  of  the  confusion  skeins,  as 
the  sage  green,  indicate  an  imperfect  perception  of  color 
short  of  complete  color  blindness. 

The  first  test  is  to  detect  the  existence  of  color  blind- 
ness of  any  kind.  A  second  test  shows  whether  it  is  red 
blindness,  or  green  blindness.  This  test  skein  is  of  light 
pink,  and  should  be  matched  by  darker  skeins  of  rose 
pink.  But  the  red  blind  will  incline  to  place  with  it 
dark  blue  or  purple,  while  the  green  blind  will  choose  the 
confusion  colors,  dark  gray  or  green.  A  third  test  skein, 
used  in  confirmation  of  the  results  obtained  with  the 
others,  is  a  bright  red.  In  red  blindness  it  will  be 
confused  with  dark  greens  or  browns.  In  green  blindness 
it  will  be  confused  with  lighter  greens  or  browns. 

Complete  color  blindness  is  rare,  but  incomplete  color 
blindness  is  quite  common.  Among  males  about  4  or 
5  per  cent,  fail  to  match  accurately  the  test  skeins, 
but  among  females  only  one-half  of  1  per  cent,  make 
similar  mistakes. 

For  positions  in  which  colored  signals  have  to  be  used 
and  obeyed,  nothing  less  than  perfect  color  perception  is 
admissible,  because  even  those  whose  color  perception  is 
but  slightly  below  the  normal,  will  err  in  quick  decisions 
as  to  signals  seen  through  fog,  snow,  or  smoke,  or  when 
in  rapid  motion. 

Other  methods  to  test  the  power  to  recognize  colors  are  : 
the  placing  of  colored  squares  or  colored  letters  upon  a 
black  background  and  determining  the  distance  at  which 
the  colors  can  be  recognized.  Or,  in  imitation  of  the 
signals  in  ordinary  use,  a  lamp-flame  at  a  considerable 
distance  from  the  eye  may  be  covered  successively  by 
glass  of  different  colors.  Or  letters  of  red  and  green  may 


PAIN.  51 

be  placed  on  a  gray  background,  where  by  a  color-blind 
eye  either  the  red  or  the  green  will  not  be  noticed. 

These  latter  tests  are  of  practical  value  principally  in 
detecting  small  central  color  scotoma,  and  for  confirm- 
ing the  results  of  the  tests  with  colored  wools ;  or 
in  demonstrating,  to  those  not  familiar  with  color  blind- 
ness, the  justice  of  decisions  based  on  the  wool  tests. 

PAIN. 

Pain,  although  a  symptom  to  which  attention  is  pretty 
certain  to  be  called  by  the  patient,  is  one  about  which  it 
is  often  difficult  to  get  a  clear  and  accurate  impression. 
As  to  its  severity  the  manifestations  of  suffering  on  the 
part  of  the  patient  are  but  an  imperfect  guide.  One 
patient  makes  little  complaint  of  pain  that  has  entirely 
prevented  sleep,  while  another  manifests  great  excitement 
over  pain  of  very  moderate  severity.  Then  too,  the  same 
morbid  process,  running  in  other  respects  the  same  course, 
will  in  one  case  cause  severe  pain  and  in  another  very 
little.  So  that  the  symptom  cannot  be  regarded  as  indi- 
cating the  severity  of  the  disease  causing  it,  as  compared 
with  similar  attacks  in  other  persons.  Even  in  a  given 
case  it  is  liable  to  vary  without  close  relation  to  the  prog- 
ress of  the  disease,  although  generally  its  marked  abate- 
ment may  be  taken  as  a  positive  sign  of  improvement. 

Different  persons  describing  pain  of  the  same  kind 
differ  greatly  in  the  terms  they  employ,  and  a  consider- 
able acquaintance  with  such  descriptions  is  necessary 
to  their  proper  appreciation.  In  any  case  it  is  well  to 
try  to  get  the  patient  to  describe  his  pain  in  more  than 
one  phrase. 

Smarting  and  Burning;  The  Feeling  of  a 
Foreign  Body. — Pain  described  as  of  this  kind,  may 
be  usually  regarded  as  due  to  conjunctivitis.  Sometimes 
the  patient  will  only  characterize  it  as  the  feeling  of 
"something  in  the  eye."  It  is  liable  to  vary  greatly  in 
severity.  It  is  aggravated  by  dust,  exposure  to  air,  light, 
or  heat,  or  by  the  use  or  movement  of  the  eyes. 


52  SMARTING   AND  BURNING. 

If  due  to  an  acute  conjunctivitis  it  will  be  accompanied 
with  noticeable  hyperemia  of  the  conjunctiva.  But  if  it 
arises  from  chronic  inflammation  the  conjunctiva  may 
appear  paler  than  normal. 

Such  pain,  usually  slight  but  sometimes  severe,  may 
follow  the  use  of  cocain  even  in  the  normal  eye,  being 
noticed  from  one  to  four  hours  after  the  use  of  the  drug. 
It  may  also  be  produced  by  the  use  of  atropin  or  one  of 
the  other  mydriatics,  in  patients  who  have  an  idiosyncracy 
toward  these  drugs.  A  common  exciting  cause  is  eye- 
strain,  particularly  beginning  presbyopia  in  persons  who 
are  trying  to  continue  to  work  without  glasses.  In  such 
cases,  there  is  usually  hyperemia  at  the  time  the  pain  is 
felt,  but  this  may  not  be  noticed,  and  only  the  pain  com- 
plained of.  Such  pain  may  also  be  due  to  a  foreign  body 
in  the  cornea  or  conjunctival  sac,  or  to  the  misplacement 
of  an  eye-lash. 

Stinging  is  a  term  which  may  be  used  to  describe  the 
same  sensation  as  is  frequently  called  smarting  or  burning, 
and  will  then  have  the  same  significance.  Or,  it  may  be 
used  to  indicate  a  totally  different  form  of  pain,  a  sudden 
lancinating  pain  due  to  cramp  of  the  ciliary  muscle,  or 
neuralgic  in  character. 

Aching  may  be  a  sort  of  extreme  spontaneous  sore- 
ness, as  in  inflammatory  disease  with  swelling  and  tension 
of  sensitive  parts  ;  or  it  may  be  a  nerve  pain  of  the  same 
character  as  headache,  sometimes  described  as  "a  head- 
ache in  the  eyes."  The  inflammatory  ache  may  be  spoken 
of  as  burning,  especially  where  there  is  conjunctival  or 
corneal  disease  present.  Its  significance  is  mainly  as  evi- 
dence of  severe  tension  of  the  parts  from  inflammatory 
exudate.  It  may  be  severe  in  corneal  disease,  but  is 
more  apt  to  be  severe  in  iritis  or  cyclitis  or  glaucoma. 
Aching  of  the  eyes,  independent  of  inflammation,  most 
frequently  arises  from  eye-strain  ;  but  sometimes  through 
choroidal  congestion,  and  sometimes  through  cramp  or  tire 
of  the  ciliary  muscle. 

Neuralgic  Pain. — This  may  be  described  as  shoot- 
ing, aching,  or  burning,  and  may  be  a  manifestation  of 


PAIN.  53 

either  functional  or  organic  nerve  disease.  In  cases  of 
ophthalmic  zoster,  or  other  serious  disease  of  the  ophthal- 
mic branch  of  the  fifth  nerve,  it  is  liable  to  be  extremely 
severe  and  persistent;  and,  in  such  cases  it  requires  care 
to  discriminate  between  pain  having  such  an  origin,  and 
that  which  might  be  attributed  to  the  inflammatory  con- 
ditions usually  present  in  such  cases. 

Fulness  or  Discomfort  of  the  Byes. — Many  cases 
of  eye-strain  present  more  or  less  constantly  this  symptom 
or  sensation,  only  occasionally  rising  into  an  actual  head- 
ache. 

Aching  Outside  of  the  Bye. — It  is  frequently 
stated  by  the  patient  that  the  eyes  are  free  from  pain, 
but  that  there  is  aching  or  pain  back  of  them.  This  fre- 
quently means  that  the  pain  is  really  in  the  eyeball ;  and 
not  upon  its  surface  or  in  the  lids ;  that  it  has  a  different 
location  from  that  produced  from  something  getting  into 
the  eye. 

But,  in  some  cases  it  seems  fair  to  refer  such  pain  to 
the  region  of  the  orbital  muscles  or  their  attachments. 
Any  severe  pain  aifecting  the  eyeball  is  likely  to  be 
referred  to  adjoining  parts.  Thus  in  glaucoma  or  iritis, 
the  pain  may  be  complained  of  as  situated  mainly  in  the 
brow  or  cheek.  In  such  cases,  however,  the  history 
generally  shows  that  it  started  in  the  eye  and  then  spread 
to  the  adjoining  parts. 

Headache. — It  ought  to  be  universally  recognized 
that  eye-strain  is  the  common  cause  of  headache.  Aside 
from  headaches  produced  by  fever,  toxemia,  and  organic 
disease  of  the  brain  and  its  membranes,  eye-strain  is 
almost  invariably  a  factor  in  the  production  of  headache. 
The  headache  of  eye-strain  is  not  of  any  special  char- 
acter. It  may  be  constant  or  intermittent ;  slight  or  severe, 
felt  only  on  the  use  of  the  eyes,  or  felt  after  their  use, 
continuous,  or  recurring  irregularly,  or  at  certain  intervals. 
It  is  aggravated  by  many  other  causes,  such  as  hunger, 
exhaustion,  exposure  to  heat  or  cold,  or  indigestion ;  or  it 
may  seem  entirely  independent  of  other  influences.  In  the 
majority  of  cases  eye-strain  is  not  the  only  factor  in  the 


54  HEADACHE. 

production  of  headache.  But  it  may  be  the  only  factor 
of  practical  importance  because  it  alone  can  be  removed, 
and  its  removal  will  give  relief.  Such  headaches  are 
generally  felt  in  the  frontal,  temporal,  or  occipital  regions. 
Rarely  are  they  most  severe  in  the  vertex. 

I/OSS  of  sensibility  to  touch  results  from  disease 
of  the  centers,  trunk,  or  peripheral  branches  of  the  fifth 
nerve.  It  is  often  not  noticed  by  the  patient.  It  is  dis- 
covered by  comparing  the  sensibility  of  one  eye  with  that 
of  the  other,  as  by  touching  one  cornea  and  then  the 
other  with  a  pledget  of  absorbent  cotton  rolled  up  to  a 
point.  The  extent  of  the  reflex  produced  by  the  touch 
of  the  cotton  on  the  cornea  is  to  be  noted,  as  well  as  the 
distinctness  of  sensation.  Decided  diminution  in  the 
sensibility  of  the  cornea  is  found  in  connection  with 
malarial  neuralgia  (brow  ague),  in  herpes,  where  it  may 
coexist  with  intense  pain,  and  in  glaucoma. 

Absence  of  pain  is  notable  in  some  diseases  where 
it  might  be  expected  to  be  present.  Thus,  severe  inflam- 
mation of  the  optic  nerve  and  retina,  or  plastic  inflam- 
mation of  the  choroid,  may  run  its  course  without  giving 
rise  to  any  pain  whatever.  Iritis  is  usually  extremely 
painful,  but  some  cases  are  quite  free  from  pain,  until  the 
disease  has  existed  for  many  days  or  weeks,  and  has  caused 
the  firm  adhesion  of  the  iris  to  the  lens  over  a  large  part 
of  the  surface  of  contact.  Cataract  is  quite  painless,  and 
complaints  of  pain  about  the  eyes  should  always  suggest 
in  old  persons  the  possibility  of  glaucoma.  (See  Chap.  X  V.) 

BIBLIOGRAPHY. 

Notes  on  Vision  and  Retinal  Perception.  H.  Snellen,  "Bowman 
Lecture,"  1896. 

Methods  of  Determining  Acuity  of  Vision.  H.  Snellen,  "  System 
of  Diseases  of  the  Eye,"  vol.  ii. 

Unilateral  Winking  as  a  Test  of  Visual  Acuity.  W.  Rider,  "  Trans. 
Amer.  Ophthalmol.  Soc.,"  1898. 

Light  Perceptive  Power  in  Diagnosis  and  Prognosis.  R.  W.  Henry, 
"Ophthalmic  Review,"  Feb.,  189(5. 

Amblyopia  of  the  Visual  Field,  Scotomas,  Hemianopsia.  H.  V. 
Wiirdemann,  "  American  Text-book." 

Cerebral  Pathology,  Visual  Centers.  S.  E.  Henschen.  "Ophthal- 
mic Review,"  Dec.,  1894,  to  Feb.,  1895. 


BIBLIOGRAPHY.  55 

Transient  Hemianopsia.     W.  Harris,  "Brain,"  1897,  part  Ixxix. 

Subjective  Symptoms  in  Eye  Disease."     Geo.  A.  Berry. 

Subjective  Visual  Sensations.  Sir  W.  K.  Gowers,  '•  Bowman  Lec- 
ture," 1895. 

Visual  Sensations  After  Cataract  Extraction.  S.  M.  Burnett, 
"Ophthalmic  Kecord,"  Jan.,  1898. 

Perimetry  and  its  Clinical  Value.  H.  Wilbrand,  "  System  of  Dis- 
eases of  the  Eye,"  vol.  ii. 

Monocular  Diplopia.  R.  Tilley,  "Trans.  Sect,  on  Ophthal.  Amer. 
Med.  Assoc.,"  1892;  G.  E.  de  Schweinitz,  "Trans.  Amer. 
Ophthal.  Soc.,"  1894. 

Normal  Color  Perception  and  Detection  of  Color  Blindness.  W. 
Thomson  and  C.  Weiland,  "System  of  Diseases  of  the  Eye," 
vols.  i.  and  ii. 

Color  Vision,  W.  de  W.  Abney.  Sampson  Low,  Marston  &  Co., 
London. 

Color  Vision  and  Color  Blindness,  J.  Ellis  Jennings. 

Color  Blindness ;  Its  Dangers  and  Detection.    B.  Joy  Jeffries. 


CHAPTER  III. 

EXTERNAL  EXAMINATION  OF  THE  EYE;  OBLIQUE 
ILLUMINATION;   THE   PUPIL. 

EXAMINATION  OF    THE   LIDS. 

THE  examination  of  the  eye  should  begin  by  careful 
inspection  of  the  lids  and  neighboring  parts  in  a  good  light 
— at  first  without  touching  the  eyes  or  in  any  way  inter- 
fering with  them.  This  inspection  may  begin  with  the 
lids  closed,  afterward  continuing  with  them  open,  and 
should  include  careful  comparison  of  the  two  sides  of  the 
face.  The  lids  may  present  some  congenital  deficiency 
— coloboma  of  the  lids — which  may  leave  part  of  the 
eyeball  continuously  exposed.  If  the  lids  be  of  normal 
formation,  inability  to  close  them  entirely  will  be  due  to 
loss  of  power  in  the  orbicularis  muscle.  This  is  liable 
to  arise  from  disease  of  the  facial  nerve.  The  portion 
distributed  to  the  orbicularis  is  frequently  involved  with 
disease  of  the  oculomotor  nerve  without  the  involvement 
of  other  portions  of  the  seventh  or  facial  nerve. 


56  EXAMINATION  OF  THE  LIDS. 

The  I/ashes. — The  position  and  regularity  of  the 
lashes  should  be  noted.  A  marked  deformity  of  the 
individual  cilia,  inequality  of  length,  and  displacement 
generally  indicate  long-continued  inflammation  of  the 
margin  of  the  lids.  Considerable  displacement  of  the 
row  of  lashes  inward — trichiasis — or  similar  displacement 
of  the  whole  lid-margin,  so  that  the  lashes  turn  in  against 
the  eyeball — entropion — commonly  indicates  chronic  dis- 
ease of  the  conjunctiva.  Displacement  of  the  lid-margins 
outward — ectropion — may  arise  from  cicatricial  contrac- 
tion of  the  skin  of  the  lid,  or  from  relaxation  of  the 
orbicularis  muscle. 

Occasionally  the  cilia  are  found  to  support  nits  or  ova 
of  the  pedieulus  pubis. 

Movements  of  the  I/ids. — The  lids  may  exhibit 
involuntary  movement,  from  slight  fibrillar  twitching  in 
the  middle  or  temporal  portions  of  the  lower  lid  to  a 
general  spasm  (blepharospasm),  which  may  prevent  their 
being  opened  for  a  considerable  period  of  time.  It  is  to 
be  noted  whether  the  patient  can  open  the  lids  to  the 
normal  extent,  and  equally  on  the  two  sides.  If  not, 
ptosis  is  present,  and  it  should  be  observed  whether  tiie 
tendency  of  the  lid  to  droop  can  be  overcome  by  increased 
muscular  exertion,  and  whether  it  depends  on  binding 
down  of  the  lid,  or  apparent  loss  of  muscular  power.  If 
the  inability  to  raise  the  lids  appears  complete,  the  sur- 
geon should  notice  whether  the  attempt  to  raise  them 
causes  any  retraction  of  the  upper  lid,  just  beneath  the 
brow.  Any  retraction  at  this  point  indicates  some  power 
in  the  elevator  of  the  lid.  If,  however,  the  movement 
of  the  lid  depends  entirely  upon  the  muscles  of  the  brow 
and  forehead,  special  effort  to  raise  it  will  be  attended 
rather  by  the  obliteration  of  any  groove  in  this  situation. 
Where  it  is  suspected  that  paralysis  of  the  elevator  is 
pretended,  this  groove  should  be  watched  while  the 
patient  is  directed  to  look  upward. 

Abnormal  retraction  of  the  lids  and  failure  of  the 
upper  lid  to  follow  the  movements  of  the  eyeball  when  it 
is  turned  down  are  signs  of  exophthalmic  goitre.  It 


EXTERNAL  EXAMINATION  OF  THE  EYE.         57 

should  be  remembered  that  the  instillation  of  cocain 
causes  an  increased  retraction  of  the  lids,  and  physostig- 
min  (eserin)  causes  fibrillary  twitching  of  the  lower  lid. 

When  the  lids  have  been  opened,  the  position  of  the 
lacrimal  puncta  should  be  ascertained,  and  whether  the 
tears  are  properly  carried  away,  or  accumulate  at  the 
lid-margin. 

Motility  of  the  Eyeballs. — This  will  frequently 
need  to  be  studied  by  the  special  tests  described  in  Chap- 
ter VIII,  but  it  should  also  be  considered  in  the  routine 
examination.  -  The  patient  is  first  asked  to  look  in  differ- 
ent directions  and  the  movements  of  the  eyes  watched. 
Then  he  may  be  requested  to  look  steadily  at  the  end  of 
a  pencil,  held  a  half-meter  in  front  of  the  eyes  and  moved 
into  different  parts  of  the  field  of  vision,  while  the  sur- 
geon observes  whether  both  eyes  properly  follow  it  in 
all  directions.  Especially  should  it  be  noticed  whether 
the  eyes  steadily  fix  upon  it  near  the  limits  of  the  visual 
field,  or  whether  they  here  begin  to  oscillate — an  indica- 
tion of  weakness  of  the  muscles  brought  into  use. 

The  pencil  should  then  be  held  directly  in  front  of  the 
face  a  little  lower  than  the  eyes  and  gradually  brought 
nearer,  until  it  is  so  close  that  they  can  no  longer  be 
turned  in  enough  to  enable  both  to  fix  upon  it.  This 
determines  the  power  of  convergence.  At  the  near  point 
of  convergence  one  of  the  eyes  remains  fixed  upon  the 
object  and  the  other  turns  outward.  With  normal  con- 
vergence this  occurs  only  when  the  fixation-point  is 
brought  within  four  inches  of  the  eye.  The  inability  to 
execute  these  movements  points  to  weakness  of  the 
muscle  or  muscles  upon  which  such  movements  depend. 

Aversion  of  the  lids  is  required  for  their  complete 
examination.  The  lower  lid  is  turned  out  by  placing  a 
finger  upon  the  skin  near  its  free  margin,  and  drawing 
the  lid-margin  down  with  a  slight  pressure  of  the  finger- 
tip, the  eye  being  at  the  same  time  rolled  strongly  upward. 
A  little  movement  of  the  finger-tip,  changing  the  direc- 
tion of  the  traction,  serves  to  expose  in  succession  all 
parts  of  the  lower  sac  of  the  conjunctiva. 


58 


EVERSION  OF  THE  LIDS. 


Eversion  of  the  upper  lid  is  really  a  folding  of  the  lid 
upon  itself.  The  method  of  doing  it  may  be  understood 
from  Fig.  14.  The  lid  must  first  be  drawn  out  from 
beneath  the  brow,  far  enough  to  give  room  for  the  fold- 
ing. On  this  account  the  eye  must  be  turned  strongly 
down,  the  patient  looking  at  the  floor  throughout  the 
whole  manipulation,  because  thus  the  elevator  of  the 
upper  lid  is  relaxed.  The  lashes  and  lid-margin  are 
lightly  seized  between  the  thumb  and  forefinger  and  the 
lid  drawn  gently  out  and  down,  as  shown  in  Fig.  14. 
With  the  other  hand,  the  end  of  a  probe,  lead-pencil,  or 
match-stick  is  placed  against  the 
lid,  just  above  the  upper  margin 
of  the  tarsal  cartilage  ;  and,  while 
by  gentle  pressure  with  its  point, 
the  lid  is  kept  from  slipping  up 
under  the  brow,  the  tension  is 
relaxed  at  the  margin,  and  the 
margin  swept  up  as  shown  by 
the  dotted  line,  until  the  cartilag- 
inous portion  lies  in  the  position 
shown  by  the  broken  lines,  folded 
over  on  the  retrotarsal  part  of  the 
lid,  fairly  everted.  To  retain  it 
in  this  position  it  is  only  needful 
to  keep  the  free  margin  well 
pressed  back  against  the  lid  ;  the 
stiffness  of  the  normal  cartilage  will  keep  the  lid  from 
unfolding  and  slipping  back. 

The  critical  point  in  this  little  manipulation  is  when 
the  tension  made  by  thumb  and  finger  is  relaxed,  and  the 
folding  attempted.  If  at  this  time  the  patient  looks  up, 
or  if  the  probe  is  placed  on  the  cartilage  (instead  of  at  its 
upper  margin),  so  that  pressure  of  the  probe  prevents  the 
sweeping  over  and  turning  out  of  the  cartilage,  the  ever- 
sion  becomes  impossible.  If  the  lid  is  thickened  and  the 
cartilage  rounded,  as  by  chronic  inflammation,  it  becomes 
difficult  to  evert  the  upper  lid,  and  sometimes  impossible 
to  keep  it  everted.  With  a  normal  lid  and  the  full  CO- 


FIG.  14.— Eversion  of  the 
upper  lid.  The  dotted  arc 
shows  where  the  lid-margin 
is  carried  up,  and  the  dotted 
lines  above  show  the  posi 
is  nelc 


tion  in  which  the  lid 
everted. 


eld 


EXTERNAL  EXAMINATION  OF  THE  EYE.         59 

operation  of  the  patient  in  looking  steadily  down,  the 
e version  is  easy  and  painless.  The  beginner  should  place 
the  probe  about  parallel  with  the  upper  margin  of  the 
cartilage,  where  it  can  remain  until  the  eversion  is  fully 
accomplished.  The  expert  will  often  dispense  with  the 
probe  altogether,  using  the  tip  of  a  finger  instead. 

Inspection  of  the  everted  lids  reveals  the  state  of  the 
conjunctival  vessels,  the  smoothness  or  roughness  of  the 
surface,  the  existence  and  character  of  exudate,  the  pres- 
ence of  a  foreign  body,  or  the  localized  grayish  discolora- 
tion of  chalazion.  Roughening  of  the  surface  by  minute 
points  that  do  not  appear  to  differ  from  the  general  sub- 
stance of  the  conjunctiva,  a  roughening  that  is  compara- 
tively uniform  like  that  of  sand-paper,  is  often  called 
"  granulated  lids."  It  is  entirely  different  from  true 
granular  conjunctivitis  or  trachoma,  in  which  the  protrud- 
ing masses  are  larger,  and  set  in  an  abnormally  red, 
thickened  conjunctiva,  like  small  grains  of  partly  cooked 
sago  or  tapioca.  Scars  may  also  be  found  on  the  lids,  but 
a  normal  lack  of  vessels  near  the  center  as  compare*d  with 
the  redder  ends  of  the  lid,  caused  by  the  pressure  of  ever- 
sion, should  not  be  misunderstood. 

Eversion  of  the  upper  lid  usually  does  not  expose  the 
whole  upper  sac  of  the  conjunctiva.  To  examine  the 
retrotarsal  fold  it  may  be  necessary  to  turn  the  eye 
strongly  down,  hold  the  lid  away  from  the  globe  without 
eversion,  and  look  up  into  the  sac  from  below.  For  this 
purpose  some  form  of  lid  elevator  is  necessary,  such  as  is 


Fie.  15.— Lid  elevator. 


shown  in  Fig.  15.  The  edge  of  this  instrument  is  gently 
insinuated  between  the  lids,  and  the  upper  lid  retracted 
with  it,  and  held  away  from  the  eyeball.  Its  use  is  some- 
times necessary  for  the  inspection  of  the  eyeball  itself,  as 
in  young  children  who  resist  the  examination,  or  when  as 


60  EXAMINATION  OF  THE  LIDS. 

after  injury  or  in  purulent  conjunctivitis  the  swelling  of 
the  lid  prevents  its  normal  opening  or  e version. 

The  study  of  the  intra-ocular  tension  is  described  in 
Chapter  XV. 

HYPEREMIA. 

Hypereraia  about  the  eyes  may  involve  one  or  more  of 
three  distinct  vascular  regions.  The  first  of  these  is  the 
lid-margins.  Redness,  usually  with  swelling,  of  the 
lid-margins  is  symptomatic  of  inflammation  in  the  hair- 
follicles  or  glands  of  these  portions  of  the  lids,  and  usually 
arises  in  connection  with  chronic  congestion  or  inflamma- 
tion of  the  conjunctiva.  Where  such  hyperemia  is  per- 
sistent or  frequently  occurs,  some  persistent  cause  should 
be  sought.  This  may  be  a  tendency  to  catarrh,  affecting 
the  conjunctiva  in  common  with  other  mucous  membranes, 
as  with  the  so-called  strumous  diathesis.  More  commonly 
it  is  a  persistent  congestion  due  to  eye-strain. 

Hyperemia  of  the  conjunctiva  may  exist  without 
any  considerable  discharge.  There  is  increase  in  the  size 
and  apparent  number  of  vessels,  and  general  redness  of 
the  membrane.  The  conjunctival  vessels  come  forward 
from  the  bottom  of  the  conjunctival  cul-de-sac  above  and 
below  the  eyeball.  Here  the  largest  trunks  become  vis- 
ible, dividing  as  they  pass  forward,  some  to  be  distributed 
to  the  bulbar,  and  some  to  the  palpebral  conjunctiva  and 
subconjunctival  tissue,  subdividing  and  growing  smaller 
as  they  approach  the  cornea  and  free  margins  of  the  lids. 
The  tissue  to  which  this  system  of  vessels  is  distributed 
is  thickest  at  the  cul-de-sac,  and  thins  out  forward, 
especially  on  the  globe.  Hyperemia  of  this  system  of 
vessels  therefore  shows  the  greatest  increase  of  redness  in 
the  retrotarsal  region,  the  redness  fading  out  into  the 
normal  color,  as  we  go  forward  toward  the  cornea  or 
toward  the  free  margin  of  the  lid.  The  increased  redness 
is  most  apparent  back"  from  the  cornea  in  the  region  of  the 
cul-de-sac.  This  sort  of  ocular  hyperemia  is  represented 
in  Fig.  16.  It  is  frequently  noticed  in  acute  general  dis- 
ease. It  may  be  present  with  fever  from  any  cause,  and 


EXTERNAL  EXAMINATION  OF  THE  EYE.         61 

attends  certain  diseases  such  as  measles.  It  may  be  pro- 
voked by  exposure  to  an  atmospheric  irritant,  such  as 
dust,  smoke,  irritant  gases,  etc.  It  may  mark  the  first 
effects  of  a  specific  irritant,  such  as  the  virus  of  gonor- 
rhea. It  may  be  reflex,  as  from  irritation  in  the  nose,  or 
may  be  produced  by  a  foreign  body  imbedded  in  the  cor- 
nea and  scratching  the  lid. 

Localized  Conjunctival  Hyperemia. — Prolonged  ex- 
posure to  the  light  and  the  heat  of  the  sun,  especially 
reflected  from  surfaces  of  white  sand  or  water,  or  to  the 
light  and  heat  of  a  hot  fire  is  liable  to  produce  hyperemia, 
sometimes  with  swelling  of  the  part  of  the  conjunctiva 


FIG.  16.— Conjunctival  hyper-  FIG.  17. — Hyperemia  of  phlyc- 

emia.  tenular  conjunctivitis. 

directly  exposed — that  is,  the  conjunctiva  of  the  globe  in 
a  triangular  area  to  the  outer  and  inner  sides  of  the 
cornea. 

Hyperemia  affecting  some  particular  portion  of  the  con- 
junctiva of  the  globe  and  the  adjoining  inner  surfaces  of 
the  lid  is  usually  due  to  traumatism,  or  the  contact  of 
some  chemical  irritant  or  hot  substance.  Portions  of  the 
lower  cul-de-sac  are  most  liable  to  be  thus  affected. 

Hyperemia  characterized  by  the  enlargement  of  the  ves- 
sels running  from  one  part  of  the  cul-de-sac  forward  upon 
the  globe,  usually  to  the  corneal  margin  and  sometimes 
extending  upon  the  cornea,  is  significant  of  phlyctenular 
disease.  This  form  is  represented  in  Fig.  17. 

Pericomeal  Redness. — In  contrast  with  conjunc- 
tival  hyperemia,  which  is  most  pronounced  at  the  pe- 
riphery of  the  sclera,  and  fades  out  as  the  cornea  is 
approached,  is  the  redness  due  to  the  enlargement  of  the 
minute  vessels  which  encircle  the  cornea  in  the  scleral 


62  PERICORNEAL  REDNESS. 

margin,  and  furnish  to  the  non-vascular  cornea  a  large 
part  of  its  nutrient  supply.  These  vessels  are  supplied 
mainly  by  the  deep  arteries  and  empty  mainly  into  the 
deep  veins  of  the  eyeball,  although  they  anastomose  freely 
with  the  peripheral  loops  of  the  conjunct! val  vessels. 
They  have  intimate  connections  with  the  vessels  of  the 
iris  and  the  ciliary  body.  Normally  they  are  quite  in- 
visible ;  but  when  dilated  they  cause  a  distinct  pink  or 
rosy  zone,  more  or  less  completely  encircling  the  cornea 
and  from  3  to  5  mm.  in  width  (Fig.  18). 

Such  hyperemia  is  indicative  of  inflammation  of  the 
cornea,  iris,  or  ciliary  body,  or  all  of  these.     When  severe, 


FIG.  18. — Pericorneal  hyper-  FIG.  19.— Enlarged  veins  in 

emia.  chronic  glaucoma. 

it  involves  the  whole  circle  of  vessels,  but  may  be  most 
noticeable  in  some  one  direction. 

It  is  a  valuable  symptom  pointing  to  a  foreign  body  in 
the  cornea,  when  such  foreign  body  has  been  lodged  there 
for  some  days.  In  corneal  ulcer  the  pericorneal  redness 
has  a  similar  relation  to  the  seat  of  the  lesion.  In  iritis 
an  incomplete  zone  of  pericorneal  redness  indicates  a  por- 
tion of  the  iris  in  which  the  inflammation  has  been  more 
violent  and  subsides  more  slowly,  such  an  incomplete  zone 
being  usually  seen  during  the  decline  of  the  disease. 

Deep  Hyperemia  of  the  Sclera. — This  may  con- 
sist in  a  general  enlargement  of  the  vessels  that  run 
comparatively  straight  toward  the  cornea,  and  which  lie 
deep  in  the  tissue;  in  contrast  to  the  conjunctival  ves- 
sels, which  are  more  tortuous,  and  move  freely  with  the 
conjunctiva  when  this  is  rubbed  about  with  the  lid.  The 
involvement  of  the  scleral  vessels  indicates  inflammation 
or  congestion  of  the  interior  of  the  eyeball. 

Another  form  of  scleral  hyperemia  is  that  in  which  the 


EXTERNAL  EXAMINATION  OF  THE  EYE.          63 

smaller  vessels  over  one  or  more  isolated  patches  of  sclera 
are  involved  along  with  the  straight  large  trunks  of  that 
region,  giving  a  patch  having  a  pink  or  deeper  purplish 
red  color.  This  appearance  indicates  a  local  inflamma- 
tion of  the  sclera. 

Enlargement  of  the  Scleral  Veins.— Enlargement 
of  the  scleral  veins  (Fig.  19)  is  still  another  form  of  hyper- 
emia. The  principal  trunks  of  these  vessels  emerge  from 
the  scleral,  4  to  10  millimeters  back  from  the  corneal 
margin,  and  pass  backward  over  the  globe.  One  or  more 
of  them  can  usually  be  detected  in  the  normal  eye.  In 
the  condition  now  referred  to  they  become  greatly  en- 
larged, prominent,  and  connected  one  with  another  by  a 
a  network  of  large  vessels  surrounding  the  cornea,  a  little 
distance  back  from  it.  This  kind  of  venous  congestion 
is  indicative  of  chronic  increase  of  intra-ocular  tension — 
glaucoma. 

Mixed  Forms  of  Hyperemia. — The  typical  varie- 
ties of  hyperemia  above  described  are  often  seen,  but  in 
many  cases  two  or  more  of  them  are  blended  together. 
Thus,  a  foreign  body  in  the  cornea,  by  scratching  the 
palpebral  conjunctiva  and  by  reflex  influence,  will  pro- 
duce an  active  hyperemia  of  the  conjunctiva,  while  its 
presence  in  the  cornea  for  a  few  hours  will  also  give  rise 
to  hyperemia  of  the  pcricorneal  zone.  Severe  iritis,  par- 
ticularly in  its  early  stages,  is  likely  to  be  accompanied 
with  conjtmctival  hyperemia.  Glaucoma  in  its  inflamma- 
tory forms  includes  an  inflammation  of  the  iris  and  a 
marked  pericorneal  zone  of  enlarged  capillary  vessels.  In 
general,  any  severe  inflammation  will  probably  cause  some 
extension  of  hyperemia  beyond  the  tract  of  vessels  whose 
involvement  would  be  typical  of  the  disease. 

SWELLING. 

Swelling,  being  due  to  the  increase  in  the  size  of  the 
vessels  or  the  escape  of  exudate  from  them,  is  necessarily 
closely  allied  to  hyperemia,  but  either  may  exist  with- 
out the  presence  of  the  other  being  noticed. 


64  SWELLING. 

Swelling  of  the  I/ids. — It  will  be  remembered  that 
the  cellular  tissue  of  the  lids  furnishes  one  of  the  com- 
mon localities  for  serous  exudation  in  chronic  renal  dis- 
ease, or  in  acute  general  edema  from  any  cause.  The 
extent  of  the  swelling  in  such  cases  varies  with  the  effect 
of  gravitation,  according  to  variations  in  the  position  of 
the  patient,  being  greatest  after  lying  down.  Great 
swelling  of  the  lids  may  result  from  emphysema,  due 
commonly  to  wounds  of  the  nose.  The  infiltration  by 
air  is  recognized  by  the  softness  and  crackling  of  the 
tissue  under  pressure,  and  increase  of  swelling  by  blowing 
the  nose. 

In  other  cases  general  swelling  of  the  lids  is  inflamma- 
tory ;  and  the  focus  of  the  inflammation  causing  it  may  be 
either  in  the  lids  or  in  the  neighboring  structures.  A 
very  small  focus  of  inflammation  may  lead  to  great  gen- 
eral swelling  of  the  lids  through  interference  with  venous 
currents  caused  by  pressure  or  thrombosis. 

General  swelling1  of  the  lids  may  also  arise  from  inter- 
ference with  the  orbital  circulation  by  pressure,  from  a 
focus  of  inflammation  or  a  new  growth  deep  in  the  orbit. 
Again,  great  and  sudden  swelling  of  the  lids  without 
other  obvious  reason  should  lead  to  the  suspicion  of  grave 
intra-ocular  disease  or  injury. 

On  account  of  the  loose  character  of  their  connective 
tissue,  the  eyelids  swell  rapidly  and  extremely  without 
great  pain.  A  tense  shining  appearance  of  the  skin  indi- 
cates that  the  swelling  is  increasing  or  at  its  height.  As 
soon  as  it  begins  to  decline,  the  skin  exhibits  a  shrunken 
wrinkled  appearance,  with  thickened  epithelium. 

Localized  swelling  of  the  lids  may  indicate  a  focus 
of  inflammation  such  as  a  small  abscess,  but  a  distinct 
tumor  is  more  frequently  chalazion.  Occasionally,  small 
cystic  tumors  form  in  connection  with  the  glands  of  the 
skin  in  this  region.  Rermoid  cysts  occurring  in  the 
region  of  the  orbit — one  of  their  favorite  positions — may 
occasion  swelling  of  the  lids.  Swelling  of  the  lids  may 
also  be  due  to  deeply  seated  growths,  such  as  gum  ma  of 
the  periosteum  of  the  orbit,  osteoma,  fibroma,  or  sarcoma 


EXTERNAL  EXAMINATION  OF  THE  EYE.         65 

of  the  orbit,  or  to  erapyema  of  the  frontal  or  ethraoidal 
sinuses.  Swelling  of  the  nasal  extremity  of  the  lower 
lid  and  of  the  side  of  the  nose  and  adjoining  parts  is  fre- 
quently caused  by  obstruction  of  the  lacrimal  duct.  The 
dilatation  of  the  sac  alone  may  cause  a  noticeable  tumor,  or 
inflammation  around  the  sac  may  be  added  to  the  dilata- 
tion. 

Prominence  of  the  Eyeball ;  Exophthalmos. — 
Apparent  prominence  of  the  eyeball  may  be  due  simply 
to  the  wide  opening  or  retraction  of  the  lids,  or  such 
retraction  may  exaggerate  a  real  prominence,  as  in  exoph- 
thalmic goiter.  Elongation  of  the  eyeball  in  high  degrees 
of  myopia  makes  it  appear  prominent.  The  nature  of 
the  trouble  here  becomes  more'  evident  when  the  patient 
turns  the  eye  strongly  toward  the  nose.  Actual  forward 
displacement  of  the  eyeball  may  result  from  paralysis  of 
one  or  more  of  the  ocular  muscles.  Complete  paralysis 
of  the  oculomotor  nerve  always  produces  some  such  dis- 
placement. It  may  be  due,  also,  to  actual  swelling  of 
the  orbital  tissue,  either  from  inflammation  (orbital  cellu- 
litis),  from  hemorrhage,  from  new  growth,  or  from  venous 
stasis  (see  Chapter  XVI). 

Swelling  of  the  Conjunctiva. — Swelling  of  the 
conjunctiva,  affecting  the  palpebral  portion,  shows  itself 
by  the  thickening  of  the  lids.  Swelling  of  the  ocular 
conjunctiva,  if  moderate  in  amount,  is  seen  chiefly  back 
from  the  cornea ;  but  if  more  extensive  it  involves  the 
membrane  up  to  the  corneal  margin,  and  may  cause  it  to 
rise  around  the  cornea  like  a  wall,  or  even  quite  overhang 
the  corneal  margin.  This  is  the  condition  known  as 
chemosis.  It  is  apt  to  arise  in  violent  conjunctival  in- 
flammation, such  as  severe  purulent  conjunctivitis,  and 
from  severe  injury  or  very  acute  inflammation  within  the 
eyeball.  The  swelling  of  chemosis  is  produced  by  a 
serous  exudation,  and  the  thickened  conjunctiva  is  com- 
paratively transparent.  Another  form  of  thickening,  as 
abrupt  as  chemosis,  but  much  less  in  height,  flattened 
rather  than  rounded,  and  often  exhibiting  a  peculiar 
appearance  of  radiating  pleats,  attended  with  little  or  no 


66  SWELLING   OF  THE  CONJUNCTIVA. 

swelling  in  other  parts  of  the  conjunctiva,  is  characteristic 
of  vernal  conjunctivis.  A  somewhat  similar  appearance 
without  hyperemia  is  not  rarely  seen  in  the  colored  race, 
as  an  anomaly. 

Great  swelling  of  the  ocular  conjunctiva,  with  cell- 
infiltration,  occurs  in  trachoma  and  diphtheritic  conjunc- 
tivitis, or  may  mark  a  late  stage  of  purulent  conjunctivitis. 

CONJUNCTIVAL  DISCHARGE. 

From  the  healthy  conjunctiva,  the  slight  secretion  and 
loosened  epithelium  are  washed  away  by  the  tears ;  and 
very  considerable  increase  over  the  normal  secretion,  if 
attended  with  a  proportionate  increase  of  the  tears,  may  be 
removed  in  the  same  manner  without  attracting  attention, 
or  showing  any  sign  upon  casual  examination.  When 
this  is  the  case,  the  pathological  discharge  may  only 
become  evident  when,  after  the  lids  have  been  closed 
during  sleep,  the  evaporation  of  tears  leaves  a  deposit  of 
such  discharge  upon  the  lid-margins,  or  causes  them  to 
stick  together  in  the  morning.  Such  adhesion  of  the  lids 
will  often  reveal  the  occurrence  of  a  discharge  when  no 
other  evidence  of  it  can  be  detected. 

Conjunctival  discharge,  if  moderate  in  amount,  con- 
sists largely  of  an  increase  of  the  normal  constituents — 
mucus  and  epithelium — but  as  it  increases  in  amount  it 
includes  an  increasingly  large  proportion  of  pus-cells. 
No  sharp  line  can  be  drawn  between  mucous  or  catarrhal 
and  purulent  discharges,  one  running  gradually  into  the 
other.  In  specific  purulent  inflammation  the  discharge 
may  be  extremely  profuse.  In  a  few  cases  the  exudate 
becomes  croupous  or  diphtheritic  in  character.  A  de- 
posit upon  the  surface  which,  when  removed,  occasions 
bleeding,  but  which  can  be  removed  without  great  force, 
is  termed  croupous.  The  diphtheritic  deposit  is  more 
intimately  incorporated  with  the  tissue,  and  cannot  be 
separated  from  it.  Where  diphtheritic  deposit  occurs, 
the  escaping  discharge,  instead  of  being  purulent,  is  com- 
monly serous  or  flocculent.  It  must  be  borne  in  mind 


EXTERNAL  EXAMINATION  OF  THE  EYE.          67 

that  recent  investigations  show  that  a  diphtheritic  deposit 
may  occur  in  the  conjunctiva  quite  apart  from  the  specific 
disease — diphtheria — and  that  true  diphtheria  may  involve 
or  even  destroy  the  eye  without  any  characteristic  diph- 
theritic deposit. 

Microscopic  Examination. — In  general,  the  micro- 
scopic or  bacteriologic  examination  of  a  conjunctival  dis- 
charge furnishes  more  definite  information  regarding  the 
true  character  of  the  case  than  the  macroscopic  appearances. 

The  discharge  is  taken  from  the  conjunctiva  with  a 
loop  of  platinum  wire  sterilized  by  passing  through  an 
alcohol  flame,  and  placed  on  a  clean  cover-glass.  Another 
cover-glass  is  placed  over  this,  and  the  two  firmly  pressed 
together  to  diffuse  the  discharge  in  a  uniform  film  over 
them.  Each  glass  is  now  grasped  in  a  spring  clip  that  will 
prevent  any  mistake  as  to  which  side  the  film  is  upon,  and 
allowed  to  dry.  A  few  drops  of  the  stain  are  then  placed 
on  the  film  for  the  required  number  of  minutes,  and  it  is 
afterward  washed  with  distilled  water,  and  decolorized  if 
desired.  It  is  then  thoroughly  dried  and  mounted  with  a 
drop  of  Canada  balsam. 

The  most  useful  stains  are  :  Strong  alcoholic  solution 
of  methylene-blue,  30  ;  one  per  cent,  solution  of  caustic 
potash,  100.  This  stains  most  bacteria  in  ten  to  fifteen 
minutes. 

Anilin  oil,  1  ;  distilled  water,  100 ;  gentian-violet  to 
saturation.  Add  alcohol  (3  parts),  and  filter.  This 
also  stains  most  bacteria  satisfactorily. 

For  the  Gram  method,  after  staining  for  ten  to  fifteen 
minutes  with  the  above  gentian-violet,  place  the  film  for 
one  or  two  minutes  in — 

lodin,  1  ;    potassium    iodid,  2 ;    distilled  water,  300. 

•Then  wash  it,  and  place  in  alcohol  until  the  color  is 
nearly  gone  ;  dry  and  mount. 

The  most  conclusive  study  of  the  bacteria  of  the  con- 
junctiva is  made  by  inoculating  with  the  matter  on  the 
loop,  tubes  of  agar,  agar-serum,  and  blood-serum,  and 
studying  macroscopically  and  microscopically  the  cultures 
thus  obtained. 


68  OBLIQUE  OR  FOCAL  ILLUMINATION. 


OBLIQUE  OR   FOCAL   ILLUMINATION. 

The  patient  is  placed  facing  the  surgeon  and  in  such  a 
position  that  the  light  shall  shine  across  his  face,  prefer- 
ably from  the  side  of  the  eye  to  be  examined.  The  exam- 
ination is  commonly  made  in  a  dark  room,  using  strong  arti- 
ficial light  concentrated  upon  the  eye  by  a  strong  lens, 
focal  illumination.  The  relative  positions  of  the  lamp- 
flame,  L,  the  lens,  and  the  patient's  eye,  E,  are  shown  in 
Fig.  20.  The  lens  should  be  held  so  as  not  to  focus  perfectly 
the  light  upon  the  eye,  for  a  uniform  diffused  illumination  is 


FIG.  20. — Manner  in  which  the  pencil  of  rays  should  be  focussed  on  the  eye  for 
oblique  illumination. 

better  than  one  which  varies  in  intensity  in  different  parts 
of  the  lighted  area,  as  completely  focussed  light  usually 
does.  Where  oblique  illumination  is  resorted  to  with 
good  daylight,  as  by  placing  the  patient  with  his  side  to 
a  large  window,  but  little  is  gained  by  the  use  of  the  con- 
densing lens.  Using  the  lens  it  is  possible  by  varying  its 
position  to  throw  light  first  on  the  surface  of  the  cornea, 
leaving  the  iris  and  pupil  in  comparative  shadowr,  then  to 
throw  the  light  upon  the  iris,  leaving  the  cornea  in 
shadow.  This  is  a  great  aid  in  determining  the  location 
of  a  particular  point,  when  there  is  considerable  opacity 
of  the  cornea. 

Many  of  the  appearances  studied  by  focal  illumina- 
tion require  for  their  full  appreciation  the  use  of  a 
magnifier.  This  may  be  an  ordinary  convex  lens  of 
about  20  D.  (two  inches  focal  distance) ;  or  a  stronger 
lens,  often  called  a  "  conical  loupe"  may  be  employed. 
The  lens  is  held  at  slightly  less  than  its  focal  distance 
from  the  eye  to  be  examined,  the  surgeon  placing  one 


BINOCULAR  MAGNIFIER. 


69 


of  his  eyes  in  line  with  it  at  a  convenient  distance. 
The  compound  microscope  has  also  been  adapted  to  the 
examination  of  the  eye  by  oblique  illumination,  by  giv- 
ing it  a  very  large  objective,  and  mounting  it  with  the 
proper  facilities  for  adjustment.  With  such  magnifiers 
only  monocular  vision  is  possible. 

To  gain  the  important  advantages  of  binocular  vision, 
a  binocular  magnifier  must  be  employed.  This  consists 
essentially  of  two  convex  lenses  joined  at  an  angle,  the 
right  eye  looking  through  one,  the  left  through  the  other. 
With  the  lenses  are  combined  prisms  which  lessen  the 
required  effort  of  convergence.  The  form  most  readily 


Fin.  21.— Binocular  magnifier  sup- 
ported by  a  spring  steel  headband, 
for  examination  of  the  eye,  and  the 
performance  of  certain  operations. 


FIG.  22.— Jackson's  binocular  magni- 
fying lens.  The  broken  lines  show  the 
directions  of  the  two  lines  of  sight 
meeting  in  the  point  looked  at. 


used  is  shown  in  Fig.  21.  A  form  more  easily  carried  in 
the  pocket  and  quite  as  useful  when  one  has  acquired  the 
mastery  of  it  is  shown  in  Fig.  22. 

With  either  form,  the  magnifier  must  be  held  with  the 
line  joining  the  centers  of  the  lenses  parallel  to  the  line 
joining  the  centers  of  the  surgeon's  pupils.  It  is  well  to 
start  with  the  magnifier  quite  close  to  the  patient's  eye, 
and  after  binocular  vision  has  been  secured,  to  withdraw 
the  lenses  almost  to  their  focal  distance  from  the  eye,  to 
get  the  benefit  of  their  full  magnifying  power. 

Focal  illumination  is  employed  to  discover  foreign 
bodies  in  the  cornea  or  anterior  chamber,  or  unoii  the 


70  BINOCULAR  MAGNIFIER. 

iris ;  to  study  opacities  or  ulcerations  of  the  cornea,  and 
to  determine  abnormalities  of  the  iris. 

Most  opacities  of  the  cornea  thus  illuminated  give 
rise  to  a  gray  appearance.  An  arc  of  gray  near  the  upper 
and  the  lower  margins  of  the  cornea,  but  with  some 
clearer  cornea  between  it  and  the  sclerotic,  is  the  so-called 
arcus  senilis.  As  age  advances,  the  arcs  extend  until 
they  form  a  complete  ring.  This  appearance  is  not  con- 
fined to  the  very  old,  but  may  occur  even  in  very  early 
childhood.  It  is  more  apt  to  occur  early,  in  the  negro 
race.  It  has  no  definite  or  special  significance,  either  as 
an  evidence  of  the  state  of  the  general  nutrition  or  of  the 
eye  itself. 

Opacities  in  the  cornea  vary  in  proportion  to  the  depth 
of  tissue  affected,  and  the  extent  of  its  departure  from 
normal.  When  slight  and  superficial,  an  opacity  is  called 
a  nebula.  If  of  limited  extent  and  more  decided,  so  that 
it  can  be  detected  by  ordinary  inspection,  but  yet  does 
not  entirely  hide  the  iris  behind  it,  it  is  a  macula.  If 
still  denser,  so  that  the  structure  and  color  of  the  iris 
cannot  be  seen  through  it,  from  its  whitish-gray  color  it 
is  called  a  leucoma.  Opacities  of  the  cornea  containing 
points  of  black  or  brown  discoloration  generally  mark  the 
site  of  a  former  perforating  ulcer,  in  the  healing  of  which 
the  iris  has  become  entangled  in  the  cicatrix,  and  remains 
adherent  to  it,  constituting  an  adherent  leucoma. 

The  reflections  from  the  surface  of  the  cornea 
should  be  carefully  observed,  the  position  of  the  eye  with 
reference  to  the  light  being  varied,  so  as  to  get  the  reflec- 
tion of  the  source  of  the  light  from  all  parts  of  the  cornea 
successively.  Any  irregularity  in  the  surface,  as  from  a 
foreign  body  or  a  conical  ulcer,  will  become  evident  in 
the  irregularity  of  the  reflection.  Very  minute  foreign 
bodies  or  abrasions  may  be  covered  by  the  corneal  mucus, 
so  as  to  give  rise  to  no  irregularity  in  the  reflection  until 
the  cornea  has  been  gently  wiped  with  absorbent  cotton 
(see  Chapter  XVII),  when  even  the  most  minute  irregu- 
larities become  manifest.  Distortions  of  the  eorneal  sur- 
face, as  by  cieatricial  changes  following  previous  inflam- 


OBLIQUE  ILLUMINATION.  71 

mation,  cause,  not  the  sharp  break  in  the  reflection  pro- 
duced by  recent  injury,  but  a  distortion  of  the  shape  of 
the  reflex.  The  cornea  being  normally  flattened  toward 
its  periphery  the  reflections  are  always  larger  there  than 
near  the  center.  Distortions  of  the  corneal  reflex  are  best 
studied  with  the  Placido  disk,  which  consists  of  alternate 
circles  of  black  and  white.  It  is  held  before  the  eye  to 
be  examined,  the  patient  being  placed  with  his  back  to 
the  light  and  the  observer's  eye  at  the  opening  at  the 
center  of  the  disk. 

The  symptoms  presented  in  the  anterior  chamber  are 
discussed  in  Chapter  XIV. 

Inspection  of  the  Iris. — Oblique  illumination  best 
reveals  any  inequalities  of  thickness  or  irregularity  of 
structure  in  the  iris,  although  differences  of  color,  espe- 
cially those  indicating  hyperemia,  are  best  seen  by  direct 
examination  in  clear  daylight.  Thickening  may  be  due 
to  parenchymatous  inflammation,  in  which  case  the  iris 
will  be  devoid  of  reflex  and  altered  in  color,  from  blue  or 
gray  toward  greenish  by  the  excess  of  blood  in  it,  and 
the  swelling  general ;  or  there  may  be  sharply  localized 
swelling  of  decidedly  different  color  from  the  surrounding 
iris,  which  indicates  a  new  growth,  as  gumma,  or  tubercle 
usually  accompanied  with  iritis,  or  sarcoma  which  grows 
at  first  slowly  and  without  evidences  of  inflammation. 
Cysts  of  the  iris  are  usually  still  slower  in  development, 
and  of  rounded  outline. 

THE  PUPIL. 

By  oblique  illumination,  the  pupil  may  be  made  to 
contract  when  the  light  is  thrown  more  directly  into  it ;  or 
dilate  as  it  is  thrown  in  more  obliquely.  Slight  departure 
of  its  form  from  a  perfect  circle  and  slight  inequalities  in 
the  size  of  the  two  pupils  are  common.  Decided  irregu- 
larity of  the  shape  of  the  pupil  is  usually  abnormal. 
Most  frequently  it  is  due  to  adhesions  of  the  iris,  either  to 
the  cornea,  anterior  synechia,  or  to  the  capsule  of  the  lens, 
posterior  synechia.  Anterior  synechia  generally  occurs  in 
connection  with  adherent  leucoma,  and  the  pupil  is  often 


72  THE  PUPIL. 

partly  hidden  by  the  opacity  of  the  cornea  when  looked 
at  from  in  front.  But  by  throwing  the  light  quite 
obliquely  into  the  eye,  and  placing  the  eye  of  the  observer 
near  the  direction  from  which  the  light  comes,  the  pulling 
forward  of  the  adherent  portion  of  the  iris  can  be  dis- 
covered. Posterior  synechia  becomes  most  evident  when 
the  pupil  is  dilated,  either  by  the  use  of  a  mydriatic  or 
by  examining  the  eye  in  the  dark  room. 

The  si^e  of  the  pupil  is  not  usually  so  important  as 
its  reaction.  It  should  be  measured  both  in  a  strong 
light  and  in  as  feeble  illumination  as  will  allow  of  an 
accurate  measurement.  The  measurement  may  be  made 
with  an  ordinary  millimeter  scale  held  as  close  as  possible 

to  the  patient's  eye,  the  surgeon's 
eye  being  some  distance  away. 
This  under-estimates  the  diam- 
eter of  the  pupil  in  proportion  as 
the  scale  is  nearer  the  surgeon's 
eye  than  is  the  pupil  measured. 
Another  method  is  to  have  a 
series  of  black  circles  on  a  card, 
or  of  circular  openings  in  a  metal 
disk,  varying  in  size  from  1  to  10 
FIG.  23.-simPie  pupiiiomcter.  mm->  with  ^  mm.  intervals,  as 

shown  in  Fig.  23.     This  is  to  be 

held  alongside  the  patient's  eye,  and  the  circle  or  open- 
ing found  which  most  nearly  corresponds  to  the  size  of 
the  pupil. 

Pupillary  Reactions. — The  pupil  is  most  mobile  in 
early  childhood,  being  at  that  time  commonly  large  in 
moderate  illumination,  dilated  widely  in  the  dark,  yet 
strongly  contracted  on  exposure  to  bright  light.  With 
increasing  age  it  becomes  more  rigid  and  mostly  smaller. 
If  the  pupils  are  small,  their  reaction  can  best  be  studied 
in  a  feeble  light,  as  by  oblique  illumination  in  the  dark 
room.  If  large,  as  after  the  use  of  a  mydriatic,  the  reac- 
tions may  be  more  distinct  in  a  stronger  light.  Absolute 
measurement  of  the  extent  of  the  reaction  has  by  itself 
but  limited  significance.  Inequalities  of  reaction  and 


REACTIONS  TO  LIGHT.  1'6 

alteration  in  the  essential  character  of  the  reaction  are 
more  important. 

Reactions  to  Light. — Normally,  contraction  of  the 
pupil  is  brought  about  by  increase  of  the  light  entering 
the  eye,  or  by  throwing  the  light  upon  a  more  sensitive 
part  of  the  retina,  such  as  the  macula.  It  may  be  tested 
by  alternately  shading  and  uncovering  the  eyes  in  day- 
light ;  but  if  not  shown  in  this  way,  the  test  is  made  in 
the  dark  room,  by  concentrating  the  light  from  the  lamp- 
flame  upon  the  pupil,  with  the  ophthalmoscope  mirror 
held  at  its  focal  distance  in  front  of  the  eye.  Turning 
the  mirror  so  that  the  light  will  fall  on  some  other  part 
of  the  face,  the  pupil  is  permitted  to  dilate ;  then  the 
pencil  of  light  being  suddenly  thrown  upon  the  eye,  the 
appreciable  time  required  for  the  reaction  allows  the 
observer  to  note  the  size  of  the  pupil  as  it  was  in  com- 
parative darkness,  before  the  sudden  contraction  due  to 
the  effect  of  the  light.  Under  these  conditions  the  slight- 
est reaction  to  light  can  be  detected.  The  turning  of 
the  light  on  and  off  the  eye  is  to  be  repeated,  until  the 
surgeon  is  fully  satisfied  as  to  its  effect.  The  first  con- 
traction to  light  is  often  followed  by  a  perceptible  dilata- 
tion, this  by  a  new  contraction,  and  so  on,  each  dilatation 
and  contraction  growing  less  until  the  pupil  becomes 
stationary.  Exaggeration  of  this  is  hippus. 

Failure  of  the  pupil  to  contract  may  be  due  to  the  use 
of  a  mydriatic,  to  adhesions  or  rigidity  of  the  iris,  to  loss 
of  function  in  the  retina  or  optic  nerve-tracts,  or  to  inter- 
ference with  the  motor  tract  from  the  pupillary  centers  to 
the  iris.  By  mydriatics,  iritic  adhesions,  or  motor  paraly- 
ses, all  movements  of  the  pupil  are  interfered  with.  If, 
however,  other  movements  are  normal,  the  cause  of  any 
impairment  of  the  light  reaction  must  lie  in  the  visual 
sensory  tract,  or  in  the  fibers  connecting  this  with  the 
centers  for  pupillary  contraction.  The  course  of  the 
sensory  tract  is  shown  in  Fig.  24 ;  from  the  retina, 
through  the  nucleus  of  the  corpora  quadrigemina,  to 
the  visual  center  in  the  occipital  lobe.  If  the  sensory 
tract  be  involved,  vision  will  be  impaired  as  much  as  or 


74  REACTION  TO  LIGHT. 

more  than  the  pupillary  reaction.  Hence,  if  vision  be 
good  and  the  pupil  fails  to  react  only  to  light,  the  fault  is 
known  to  lie  in  the  fibers  connecting  the  optic  tract  (sen- 
sory), with  the  centers  (motor)  for  pupillary  contraction. 

A  pupil  showing  absence  of  the  reaction  to  light,  where 
vision  and  other  pupillary  movements  remain  good,  is 


FIG.  24.— Tracts  concerned  in  the  pupillary  reflex,  the  efferent  or  motor  tract 
being  represented  by  the  dotted  lines. 

known  as  the  Argyll-Robertson  pupil.  It  is  an  important 
early  symptom  of  locomotor  ataxia  or  multiple  sclerosis. 

It  should  be  borne  in  mind  that  each  pupil  reacts 
freely  to  light  thrown  in  the  other  eye — consensual  reac- 
tion— and  that  even  changes  of  light  upon  the  closed  lids 
of  the  other  eye  may  cause  a  noticeable  reaction.  Where 
loss  of  reaction  to  light  is  due  to  involvement  of  fibers 
connecting  the  sensory  and  motor  tracts,  the  pupil  com- 
monly remains  contracted  in  the  darkened  room.  This 
has  been  taken  to  indicate  that  the  condition  was  one  of 
excessive  in  nervation  of  the  sphincter  of  the  iris,  a  view 
supported  by  the  occasional  dilatation  of  the  pupil  and 
the  restoration  of  the  light  reflex  in  late  cases  of  sclerosis, 
after  complicating  lesions  like  apoplexy.  Interference 
with  the  sensory  tract  causes  complete  blindness  before 
it  destroys  the  pupillary  reaction  to  light.  When  loss  of 
light-reaction  does  occur,  it  is  important  evidence  corrob- 
orative of  a  patient's  statement  that  an  eye  has  become 
quite  blind. 

The  light-reaction  is  lost  only  when  the  interruption 
of  the  sensory  tract  is  in  front  of  the  corpora  quadrigem- 
ina  where  the  fibers  which  connect  it  with  the  motor 


GENERAL  REACTIONS  OF  THE  PUPIL.  75 

tract  are  given  off.  Blindness  due  to  a  lesion  back  of 
this  point  may  be  absolute  without  interference  with  the 
pupillary  reaction.  This  fact  is  of  importance  in  localiz- 
ing a  lesion  causing  hemianopsia.  A  single  lesion  of  the 
sensory  tract  back  of  the  optic  chiasm  causes  hemianopsia. 
If  the  lesion  lie  between  the  chiasm  and  the  corpora 
quadrigemina,  it  also  destroys  the  retiex  of  the  pupil  to 
light  thrown  upon  the  blind  half  of  the  retina,  although 
the  reflex  remains  perfect  to  light  thrown  on  the  seeing 
half  of  the  retina.  This  is  the  so-called  Wernicke  reac- 
tion of  the  pupil  or  hemiopic  pupillary  inaction.  If  the 
lesion  causing  the  hemianopsia  be  back  of  the  corpora 
quadrigemina,  it  will  not  interfere  with  the  reaction  of 
the  pupil  to  light  thrown  upon  any  part  of  the  retina. 
Hence,  hemiopic  loss  of  the  pupillary  reflex  points  to 
lesion  of  the  optic  tract,  between  the  chiasm  and  the 
corpora  quadrigemina,  or  within  the  latter.  The  search 
for  this  reaction  must  be  carefully  made  in  a  dark  room, 
with  light  carefully  excluded  from  the  seeing  halves  of 
the  retinas. 

Sloivness  of  the  reaction  of  the  pupil  to  light,  or  ine- 
(jtKility  of  the  two  pupik,  or  of  the  same  pupil  at  different 
times,  is  an  indication  of  chronic  degenerative  changes  in 
the  central  nervous  system.  Complete  loss  of  the  light- 
reaction  may  be  caused  by  any  lesion  of  the  optic  nerve 
or  eye  that  causes  complete  blindness.  Vision,  however, 
may  be  very  greatly  impaired  with  but  little  loss  of  the 
pupillary  light  reflex  ;  and  even  when  blindness  seems 
complete,  and  by  ordinary  tests  the  pupil  seems  not  to 
react  to  light,  complete  darkness  may  cause  slow  dilata- 
tion, and  exposure  to  strong  sunlight  a  slow  contraction. 

General  Reactions  of  the  Pupil. — Normally  the  pupil 
dilates  under  nervous  excitement,  fear,  surprise,  dur- 
ing hunger,  in  anemia,  or  from  other  causes  of  nervous 
instability.  It  contracts  with  the  effort  to  focus  the  eyes 
for  near  objects,  and  with  the  convergence  or  turning  in 
of  the  visual  axes.  It  also  contracts  strongly  during 
sleep. 

The  test  of  contraction  with  convergence  and  accom- 


76  ASSOCIATED  CONTRACTION. 

modation — associated  contraction — is  to  be  made  by 
getting  the  patient  to  look  first  at  a  distant  object,  and 
then  at  the  point  of  a  pencil  or  similar  object  held  close 
to  the  eye  in  a  line  with  the  distant  object,  to  avoid  any 
change  of  illumination.  Looking  alternately  from  one  to 
the  other,  the  changes  in  the  size  of  the  normal  pupil  are 
readily  observed.  Failure  of  the  pupil  to  contract  with 
convergence,  or  great  sluggishness  of  contraction,  indi- 
cates some  fault  in  the  motor  apparatus.  Dilatation  of 
the  pupil  and  sluggish  reaction  with  convergence  occur  in 
glaucoma,  and  large  pupils  in  elderly  persons  should 
always  bring  this  disease  to  mind. 

If  not  due  to  glaucoma  or  injury  in  the  eye,  or  the  use 
of  a  mydriatic,  moderate  dilatation  of  the  pupil,  with 
failure  to  contract  to  any  stimulus,  indicates  lesion  of  the 
oculomotor  nerve  or  its  nucleus  in  the  pons.  Generally 
if  the  dilatation  of  the  pupil  be  accompanied  by  the  loss 
of  power  in  the  external  muscles  supplied  by  the  third 
nerve,  the  lesion  is  located  somewhere  in  the  nerve-trunk. 
If  the  dilatation  or  partial  dilatation  of  the  pupil  and 
failure  to  contract  under  stimulus  be  accompanied  only 
with  loss  of  accommodation,  they  constitute  the  condition 
known  as  ophthalmopleyia  internet,  and  depend  upon  some 
lesion  involving  the  nucleus  from  which  the  nerve  pro- 
ceeds. 

Persistent  contraction  of  the  pupil  is  due  to  narcotic 
poisoning  (opium)  or  to  cerebral  irritation,  as  from  inflam- 
matory disease  of  the  brain  and  its  membranes,  or  from 
the  congestion  which  attends  cerebral  apoplexy  or  the 
early  stages  of  the  acute  fevers.  It  may,  however,  occur 
from  a  lesion  involving  the  inhibitory  fibers  of  the  cervi- 
cal spinal  cord.  But  the  most  common  cause  of  contracted 
pupil — always  to  be  thought  of  and  sought  for — is  the 
adhesion  of  the  iris  to  the  lens  capsule — posterior  syne- 
chia.  Such  adhesion,  if  extensive,  causes  absolute  im- 
mobility of  the  pupil,  generally  in  a  state  of  great  con- 
traction. 

Persistent  dilatation  of  the  pupil,  aside  from  blindness, 
glaucoma,  and  the  use  of  mydriatics,  is  liable  to  be  caused 


GENERAL  REACTIONS  OF  THE  PUPIL.  77 

by  irritation  of  the  upper  portion  of  the  spinal  cord,  as 
in  the  early  stages  of  organic  disease. 

The  color  of  the  pupil  by  oblique  illumination  is  not 
usually  clear  black,  but  the  anterior  surface  and  the  sub- 
stance of  the  lens  reflect  some  light,  giving  it  a  slightly 
gray  tinge.  This  becomes  more  decided  as  the  patient 
grows  older,  and  after  middle  life  is  always  very  notice- 
able and  liable  to  be  mistaken  for  cataract.  It  is  ren- 
dered most  evident  by  allowing  the  light  to  fall  upon  the 
eye  very  obliquely,  and  viewing  the  pupil  obliquely  over 
the  bridge  of  the  nose  from  the  opposite  side. 

In  this  way  there  may  be  observed,  sometimes  even  in 
children,  a  group  of  radiating  lines  situated  in  the  an- 
terior surface  of  the  lens,  which  is,  however,  quite  phys- 
iological and  not  to  be  mistaken  for  commencing 
opacity. 

By  dilating  the  pupil  and  bringing  the  source  of 
illumination  father  more  in  front  of  the  eye,  the  whole 
thickness  of  the  lens  can  be  inspected  and  opacities 
revealed  in  any  part  of  it,  or  in  the  anterior  portion  of 
the  vitreous  humor.  The  results  obtained  by  focal 
illumination,  however,  should  not  be  relied  on,  in  any 
doubtful  case,  without  confirmation  by  examination  with 
the  ophthalmoscope. 

BIBLIOGRAPHY. 

Atlas  of  the  External  Diseases  of  the  Eye,  ( ).  Haab,  edited  by  G.  E. 

de  Schweinitz.     W.  B.  Saunders,  Philadelphia. 
On  a  Compound  Microscope  for  Viewing  the  Eye,  Lucien  Howe. 

"N.  Y.  Med.  Jour.,"  June  17,  1899. 
The  Binocular  Magnifier,  E.  Jackson.    "Trans.  Anuer.  Ophthalmol. 

Hoc.,"  1896;  "Annals  of  Ophthalmol,"  Oct.,  1896. 
The  Pupil.     Handbook  of  Diseases  of  the  Eye,  Chap.  XT.,  H.  R. 

Swanzy.     H.  K.  Lewis,  London. 
The  Argvll-Robertson   Pupil,  T.  K.  Monro.     "  Amer.  Jour,  of  the 

Med."  Sci.,"  July,  1896. 
Loss  of  Pupillary  Light  Reaction,  W.   A.   Turner.     "Roy.  Lond., 

Ophthal.  Hosp.  Rep.,"  vol.  xiii,  pt.  iii. 
Hemiopic   Pupil   Reaction,  S.  E.  Henscheu.     "Ophthal.  Review," 

Dec.,  1894. 
The  Pupil  Reflex  in  Absolute  Blindness,  Geo.  C.  Harlan.     "Trans. 

Amer.  Ophthalm.  Soc.,"  1896. 


78 


THE  OPHTHALMOSCOPE. 


CHAPTER   IV. 

OP-HTHALMOSCOPIC  DIAGNOSIS. 

THE  OPHTHALMOSCOPE. 

THE   ophthalmoscope  enables  the  surgeon  to  inspect 
the  interior  of  the  eyeball  through  the  cornea  and  the 

crystalline  lens,  which  mag- 
nify the  details  of  the  fundus 
10  to  20  diameters,  according 
to  the  refraction  of  the  eye. 
It  consists  essentially  of  a 
mirror  for  throwing  the  light 
into  the  eye,  with  a  central 
perforation  through  which 
the  surgeon  can  look  in  the 
direction  that  the  light  is 
thrown,  and  a  series  of  lenses 
to  focus  the  light  from  the 
structures  examined. 

The  form  of  ophthalmo- 
scope preferred  by  the  author 
is  illustrated  in  Fig.  25. 
The  mirror  is  swung  upon 
a  pivot,  placed  at  each  end, 
so  that  it  can  be  tilted  to  an 
angle  of  25  to  30  degrees 
with  the  back  plate  that 
shades  the  surgeon's  eye  from 
the  light.'  The  aperture  in 
the  mirror  is  about  2  milli- 
meters in  diameter.  The 
lenses  are  arranged  in  two 
slides  just  behind  the  mirror. 
They  are  moved  by  the  tip 
of  the  forefinger  acting  on 
milled  projections  from  the 
FIG.  25.-Author'S  ophthalmoscope,  lower  ends  of  the  slides.  This 


OPHTHALMOSCOPIC  DIAGNOSIS.  79 

allows  the  use  of  all  lenses  and  combinations  of  lenses 
of  which  the  instrument  is  capable  without  removing  it 
from  the  eye.  By  taking  out  a  screw  from  the  lower  end 
of  the  stem,  the  slides  of  lenses  are  readily  removed  for 
cleaning.  The  lens  series  furnished  by  the  instrument 
includes  either  convex,  1,  2,  3,  4,  5,  6,  8,  11,  and  15  D. ; 
and  concave,  1,  2,  3,  4,  5,  6,  7,  8,  9,  10,  15,  and  30  D. ; 
or  convex,  0.5,  2,  1.5,  2,  2.5,  3,  3.5,  4,  7.5,  and  10  D. ; 
and  concave,  1,  1.5,  2,  2.5,  3,  4,  5,  6,  7,  8,  9,  10,  and 
25  D.  Either  series  is  sufficiently  complete  for  all  prac- 
tical purposes ;  but  the  former  is  preferable,  the  0.5  D. 
intervals  being  of  no  value  except  to  the  expert  who  is 
constantly  measuring  refraction  with  the  ophthalmoscope. 

There  are  many  other  good  forms  of  ophthalmoscope, 
most  of  them  having  the  lenses  arranged  in  one  or  more 
disks.  That  of  Loring  is  one  of  the  best,  except  that 
the  large  sight-hole  in  the  mirror  fits  it  rather  to  measure 
refraction  than  to  examine  the  fundus  of  the  eye.  The 
most  common  fault  is  in  the  direction  of  elaborating  the 
instrument  into  a  machine  that  could  do  things  that  one 
never  wants  to  do  with  an  ophthalmoscope. 

In  general,  a  good  ophthalmoscope  should  have  a  thin 
tilted  mirror  with  a  small  sight-hole,  free  from  reflections. 
Reflections  are  to  be  tested  by  trying  the  instrument  in 
the  thoroughly  darkened  room.  Any  imperfection  of 
the  kind  causes  a  luminous  haze  in  front  of  the  surgeon's 
eye,  which  interferes  with  the  seeing  of  the  conditions  in 
the  patient's  eye.  The  lenses  must  be  furnished  with  a 
spring  catch  that  will  cause  each  lens  to  stop  at  its  proper 
position  before  the  sight-hole.  All  lenses  should  be 
available  without  removing  the  instrument  from  the  eye 
and  without  bringing  the  surgeon's  hand  too  much  before 
the  patient's  face.  It  should  be  simple,  and  should 
include  no  unnecessary  lenses,  cumbersome  "  improve- 
ments," or  useless  parts. 

Why  any  special  apparatus  is  necessary  to  inspect  the 
interior  of  the  eye,  and  the  exact  function  of  the  lenses 
will  be  explained  in  the  section  on  "the  measurement  of 
refraction"  with  the  ophthalmoscope,  Chapter  V.  Two 


80  THE  OPHTHALMOSCOPE. 

essentially  different  methods  of  using  the  ophthalmoscope, 
the  direct  and  the  indirect,  are  employed.  The  latter, 
formerly  much  used,  is  now  only  resorted  to  in  special 
cases.  If  not  otherwise  stated,  it  will  be  understood  that 
the  direct  method  is  here  referred  to.  The  optical  details 
of  both  will  be  described  in  Chapter  Y. 

Methods  of  Using  the  Ophthalmoscope. — The 
ease  with  which  an  ophthalmoscopic  examination  can  be 
made  depends  upon  the  size  of  the  pupil.  If  this  be  not 
dilated  by  a  mydriatic,  it  is  necessary  to  make  the  exam- 
ination in  a  darkened  room.  The  patient  is  placed  with 
his  back  to  the  light,  which  should  be  readily  movable 
from  side  to  side.  The  surgeon  then  places  himself 
exactly  alongside  of  the  patient,  but  facing  in  the  oppo- 
site direction,  sitting  on  the  right  side  to  examine  the 
patient's  right  eye  and  on  the  left  side  to  examine  the  left 
eye.  The  lamp-flame,  L  (Fig.  26)  is  then  drawn  far 


FIG.  26.— Horizontal  section  showing  relative  position  of  surgeon  (S),  patient 
(P),  and  lamp-flame  (L)  during  ophthalmoscopic  examination. 

enough  to  the  side  of  the  eye  to  be  examined  for  the 
light  from  it,  just  escaping  the  temple  of  the  patient,  to  fall 
on  the  outer  lashes.  If  it  be  more  behind  the  patient's  head, 


OPHTHALMOSCOPIC  DIAGNOSIS.  81 

P,  it  will  be  cut  off  from  the  mirror  when  this  is  brought 
close  to  the  patient's  eye.  If  it  be  more  to  the  side  of  the 
patient,  it  may  be  cut  off  from  the  mirror  by  the  surgeon's 
nose,  and  will  require  an  exceedingly  oblique  position  of 
the  mirror  in  order  to  reflect  it  into  the  patient's  eye.  The 
patient  is  to  keep  his  head  directed  forward,  inclined 
toward  the  side  of  the  surgeon,  and  to  turn  the  eyes  a 
little  to  that  side.  The  ophthalmoscope  is  to  be  held  in 
the  right  hand  and  to  the  surgeon's  right  eye  to  examine 
the  patient's  right  eye,  and  the  left  hand  and  eye  are  used 
for  the  patient's  left  eye.  The  mirror  is  tilted  to  face 
toward  the  light ;  and,  as  a  preliminary,  the  ophthalmo- 
scope is  held  about  12  inches  from  the  eye  to  be  exam- 
ined, in  such  a  way  as  to  throw  the  light  upon  it. 

The  corneal  reflex,  a  small  bright  image  of  the  source 
of  light,  appears  on  the  part  of  the  cornea  perpendicular 
to  the  direction  in  which  the  surgeon  looks ;  and  beside 
the  corneal  reflex,  the  pupil,  previously  black,  becomes 
occupied  with  a  red  glow — the  fundus  reflex — which 
varies  in  hue  according  to  the  brightness  of  the  illumina- 
tion and  the  color  of  the  fundus  of  the  eye  under  exam- 
ination, being  brighter  in  light  and  duller  in  dark  eyes. 

OPACITIES  IN  THE  MEDIA. 

Having  obtained  the  fundus  reflex,  the  surgeon  is  to 
observe  whether  it  is  interrupted  by  any  black  dots  or 
masses.  Such  black  spots  indicate  opacity  somewhere 
between  the  choroid  and  the  observer's  eye.  They  may 
be  produced  by  a  bubble  of  air  on  the  cornea,  by  a  for- 
eign body  in  the  cornea,  by  specks  of  exudation  on  the 
anterior  capsule  of  the  lens,  by  isolated  opacities  of  the 
lens,  or  by  opacities  of  the  vitreous.  If  an  opacity  is 
discovered,  the  presence  of  other  opacities  should  be 
determined  by  the  surgeon  moving  his  head  to  different 
points  of  views,  or  the  patient  looking  in  different  direc- 
tions. Such  movements  will  also  produce  an  apparent 
change  in  the  position  of  the  opacities  seen,  and  thus 
indicate  their  position. 


82  OPACITIES  IN  THE  MEDIA. 

The  apparent  position  of  an  opacity  is  always  referred 
to  the  margin  of  the  pupil.  Opacities  situated  in  the 
plane  of  the  pupil  preserve  their  relation  to  it  from  what- 
ever direction  they  are  seen.  Those  situated  in  front  of 
the  pupil  appear  to  move  across  it  in  the  direction  opposite 
to  that  of  the  movement  of  the  surgeon's  eye  or  in  the 
same  direction  as  the  patient's  eye  is  turned.  Those 
situated  behind  the  pupil  appear  to  move  across  it  in  the 
direction  in  which  the  surgeon's  eye  is  moved,  or  in  the 
direction  opposite  to  that  of  the  movement  of  the  patient's 
eye.  The  reason  of  this  is  shown  in  Fig.  27  in  which  77 
represents  the  plane  of  the  iris,  A  an  opacity  in  front  of 
the  pupil,  as  a  foreign  body  in  the  cornea,  B  an  opacity 
in  the  pupil  as  an  anterior  polar  cataract,  and  C  an 


M 

^^ 

FIG.  27.— Apparent  position  of  opacities,  in  front  of,  at,  or  behind  the  pupil. 

opacity  behind  the  pupil,  such  as  a  posterior  polar  cata- 
ract. When  the  eye  is  looked  at  from  the  direction  J/, 
the  opacity  at  A  appears  to  be  situated  at  x  near  the 
upper  margin  of  the  pupil,  and  the  opacity  at  ('appears 
at  y,  near  the  lower  margin  of  the  pupil.  As  the  sur- 
geon's eye  moves  from  M  to  N,  the  opacity  at  A  appears 
to  go  in  the  opposite  direction,  while  that  at  C  appears  to 
move  witli  it,  so  that  on  reaching  A7,  A  appears  to  be  at 
y  and  C  at  .r;  but  from  all  directions,  R  maintains  its 
position  at  the  center  of  the  pupil.  The  nearer  the 
opacity  is  to  the  plane  of  the  pupil,  the  slower  its  move- 
ment ;  and  the  farther  away  it  is  from  the  plane  of  the 


OPACITIES  IN  THE  MEDIA.  83 

pupil,  the  more  rapid  its  apparent  movement.  In  this 
way  the  depth  of  the  opacity  within  the  eyeball  may  be 
roughly  estimated. 

An  aid  in  this  estimate  is  the  apparent  movement  of 
the  opacity  as  compared  with  that  of  the  corneal  reflex. 

In  all  positions,  the  reflex  comes  from  the  direction  of 
the  center  of  curvature  for  the  cornea.  For  the  direction 
M  it  will  be  seen  at  m.  For  the  direction  N  it  will  be 
seen  at  n.  If  then,  the  opacity  at  6*  be  situated  exactly 
at  the  center  of  curvature  of  the  cornea,  its  apparent 
movement  across  the  pupil  will  exactly  keep  pace  with 
the  apparent  movement  of  the  light-reflex  of  the  cornea. 
If  the  opacity  be  situated  deeper  in  the  eye  than  the 
center  of  curvature  of  the  cornea,  it  will  move  more 
rapidly  across  the  pupil,  and  get  ahead  of  the  corneal 
reflex.  If  it  be  situated  in  front  of  the  center  of  curva- 
ture of  the  cornea,  it  will  move  more  slowly  across  the 
pupil,  and  lag  behind  the  corneal  reflex.  Thus  one  can 
determine  whether  a  foreign  body  is  in  front  of  or  behind 
the  center  of  curvature  of  the  cornea.  The  position  of 
the  center  of  curvature  of  the  cornea  can  be  accurately 
determined  with  the  ophthalmometer  (see  Chap.  VII). 

The  position  of  opacities  deep  in  the  vitreous  humor 
may  be  determined  by  measurement  of  their  refraction 
with  the  ophthalmoscope.  Opacities  in  the  cornea  and- 
lens  are  commonly  fixed  ;  in  the  aqueous  humor  they  float 
freely,  and  in  the  vitreous  they  move  with  a  freedom 
dependent  on  its  fluidity  or  loss  of  normal  consistency. 

Opacities  arise  in  the  cornea  from  foreign  bodies, 
injuries,  inflammation,  and  deposits  on  the  posterior  sur- 
face in  connection  with  iritis.  Those  of  the  vitreous 
indicate  inflammation  of  the  choroid  or  ciliary  process,  as 
do  also  those  of  the  lens,  in  some  cases. 

Crystals  of  cholesterin  may  be  encountered  in  the  cor- 
nea, aqueous,  lens,  vitreous,  or  retina.  They  may  appear 
as  flakes  of  opacity,  or  when  the  light  strikes  them  at  a 
certain  angle  show  brilliant  iridescence.  They  are  not 
incompatible  with  normal  vision,  although  more  commonly 
seen  in  the  eyes  that  have  undergone  degenerative  changes. 


84  EXAMINATION  OF  THE  EYE-GROUND. 


EXAMINATION  OF  THE  EYE-GROUND. 

The  Optic  Disk.— Having  searched  the  dioptric 
media  for  opacities,  the  ophthalmoscopic  examination  is 
directed  to  the  region  of  the  optic  disk.  The  optic  nerve 
enters  10  or  12  degrees  to  the  nasal  side  of  the  posterior 
pole  of  the  eyeball.  To  examine  it  the  patient  should 
turn  his  eyes  slightly  toward  the  surgeon,  who,  keeping 
still  10  degrees  or  12  degrees  to  the  temporal  side  of  the 
visual  axis,  is  able  to  look  in  the  direction  of  the  optic 
disk  without  getting  in  front  of  the  patient's  face.  To 
find  the  direction  of  the  disk  the  surgeon  watches  the 
fundus  reflex,  and  moves  his  eye  until  the  red  glare  from 
the  pupil  becomes  noticeably  brighter  and  of  a  lighter 
color,  indicating  that  the  optic  disk  has  been  brought  in 
line  with  it.  Keeping  as  near  as  possible  in  this  direc- 
tion, the  surgeon  brings  his  own  eye  with  the  ophthalmo- 
scope as  close  as  possible  to  that  of  the  patient,  as  shown 
in  Fig.  26.  During  this  movement  care  must  be  taken 
to  keep  the  mirror  so  turned  that  it  will  steadily  reflect 
light  into  the  patient's  pupil — a  thing  difficult  at  first, 
although  easily  done  after  long  practice. 

It  is  not  sufficient  for  some  part  of  the  light  from  the 
mirror  to  fall  upon  the  patient's  pupil.  The  light  must 
enter  the  patient's  eye  from  the  part  of  the  mirror  im- 
mediately around  the  sight-hole.  The  form  of  til  ting- 
mirror  illustrated  in  Fig.  25,  the  one  commonly  used  on 
American  ophthalmoscopes,  is  much  larger  than  is  of 
value  for  the  direct  ophthalmoscopic  examination,  in 
which  only  a  circle  about  15  mm.  in  diameter  immediately 
around  the  sight-hole  can  be  utilized.  Light  may  fall  on 
the  eye  from  other  parts  of  the  mirror  without  giving  the 
surgeon  any  fundus  reflex  whatever. 

With  the  mirror  properly  directed  and  the  surgeon's  eye 
as  close  as  possible  to  that  of  the  patient — generally  within 
one  or  two  inches — there  will  appear  in  the  pupil  an  area 
of  light  color,  surrounded  by  the  darker  red  of  the  fundus 
reflex.  By  relaxing  the  accommodation  or  pushing  up 
the  proper  lens,  the  margin  of  this  area  with  the  other 


OPHTHALMOSGOPIC  DIAGNOSIS. 


85 


details  of  the  fund  us  will  become  clear.  It  is  then  found 
that  the  area  is  circular  or  somewhat  oval,  generally  with 
the  long  axis  vertical,  and  presents  somewhat  the  appear- 
ance shown  in  Fig.  28  and  in  Figs.  1,  3,  4,  and  5  of  the 
colored  plates  I  and  II. 

Its  color  is  usually  rather  pink  or  cream,  vet  in  contrast 
with  the  darker  red  around,  it  looks  almost  white.  In 
some  eyes  it  is  quite  gray,  or  even  browrn  pigment 
is  deposited  in  its  connective-tissue  stroma.  Striking 


FIG.  28.— The  normal  fundus.  The  darker  vessels  are  veins,  the  lighter 
arteries.  The  dark  specks  on  the  oval  optic  disk  are  spaces  in  the  lamina  crib- 
rosa.  The  light  crescentic  spot  represents  the  reflex  from  the  fovea. 

anomalies  are  occasionally  encountered.  The  common 
variations  of  color,  however,  depend  on  the  vascularity  of 
the  nerve-head.  It  is  generally  darker  on  the  nasal  side 
and  paler  at  the  center  of  the  disk  and'  toward  the  tem- 
poral margin.  At  the  border  of  the  disk  may  be  seen 
points,  or  a  complete  ring  of  brown  or  black,  the  "chor- 
oidal  ring"  (see  Plates  I  and  II).  Within  this  may  often  be 


86  EXAMINATION  OF  THE  EYE-GROUND. 

noticed  a  crescent  to  the  temporal  side  (Plate  II,  3),  or  a 
complete  ring  of  white  surrounding  the  disk  (Plate  II,  4), 
the  part  of  the  sclera  exposed  by  a  comparatively  large 
opening  in  the  choroid. 

Upon  the  disk  appear  as  red  lines,  the  retinal  vessels, 
the  veins  darker  and  more  crimson  in  color,  the  arteries 
lighter  and  more  scarlet.  The  larger  vessels  show  a 
white  glistening  line  along  their  centers — the  light  streak. 
The  smaller  arteries  and  veins  are  more  alike,  so  that 
whether  a  certain  vessel  is  an  artery  or  a  vein  can  only  be 
ascertained  by  noticing  the  larger  vessel  with  which  it  is 
connected.  Frequently  the  normal  veins  may  be  seen  to 
pulsate  where  they  turn  to  pass  back  into  the  optic  nerve, 
but  pulsation  of  the  arteries  is  abnormal.  The  largest 
branches  pass  upward  and  downward,  then  bend  toward 
the  temporal  side.  Occasionally  a  vessel  of  medium  size 
does  not  arise  from  the  general  system  of  vessels  upon  the 
disk,  but  appears  independently  near  the  temporal  margin, 
passes  a  little  on  to  the  disk,  and  then  turns  back  and  is 
distributed  to  the  retina  toward  the  macula.  Such  are 
called  cilioretinal  vessels  (Plate  II,  1). 

In  the  lighter  area  at  the  center  of  the  disk  may 
often  be  seen  a  dark  stippling,  a  network  of  white 
with  dark  interspaces  (See  Plate  II,  4  and  6,  and 
Fig.  28).  This  network  is  the  lamina  cribrosa,  the 
continuation  of  the  sclerotic  across  the  space  through 
which  the  optic  nerve  enters  the  eye,  the  white  network 
being  the  connective-tissue  bundles,  and  the  dark  inter- 
spaces the  openings  through  which  the  nerve-fibers  pass. 

The  center  of  the  optic  disk  is  commonly  marked  by  a 
depression — the  physiological  cup — which  varies  greatly 
in  depth  and  form  in  normal  eyes.  Its  presence  and 
depth  are  most  clearly  demonstrated  by  measuring  the 
refraction  of  different  portions  of  the  disk-surface.  Gen- 
erally it  is  somewhat  conical  in  shape.  Compare  Plate 
I,  1,  Plate  II,  3  and  4,  and  Figs.  28,  29,  33,  and  34. 

Usually  the  nasal  side  is  more  abrupt  than  the  tem- 
poral. The  central  artery  and  the  central  vein,  or  their 
primary  branches,  first  make  their  appearance  at  the  bot- 


OPHTHALMOSCOPIC  DIAGNOSIS.  87 

torn  of  this  cup,  then  pass  up  its  sides  or  even  into  the 
nerve-tissue  around  it,  and  emerge  on  the  level  of  the 
disk.  Usually  the  diametef  of  the  "  physiological  cup  " 
approaches  half  that  of  the  optic  disk ;  but  it  may  be 
larger  or  smaller  than  this,  or  the  cup  may  be  entirely 
absent  without  indicating  disease. 

The  normal  color  of  the  ftindllS,  or  eye-ground, 
varies  greatly.  The  retina,  which  is  almost  transparent, 
is  only  seen  when  the  tissue  behind  it  is  of  comparatively 
dark  color.  The  pigment-layer  of  the  retina  presents  all 
variations  from  complete  transparency  to  almost  complete 
opacity,  according  to  the  amount  of  pigment  deposited  in 
the  cells.  When  transparent  the  color  of  the  fundus  is 
the  color  of  the  structures  behind  it ;  when  opaque,  noth- 
ing back  of  this  layer  is  visible.  The  fundus  is  compara- 
tively dark  in  the  dark  races,  brown,  or  mahogany, 
rather  than  red.  With  such  a  background,  the  retina 
will  be  noticed  as  a  gray  veil,  thickest  above  and  below 
the  optic  disk,  where  it  is  somewhat  striated,  the  stria? 
running  in  the  direction  of  the  bundles  of  nerve-fibers, 
first  upward  and  downward,  and  then  curving  around 
above  and  below  the  region  of  the  macula.  The  retinal 
veil  becomes  thinner  as  we  go  forward  toward  the  periph- 
ery of  the  retina,  until  it  is  no  longer  visible. 

When  less  pigment  is  deposited  in  the  retinal  pigment- 
layer,  more  of  a  red  glow  is  transmitted  from  the  choroid 
behind  it,  and  with  the  increase  of  light  coming  through 
it,  the  retina  itself  becomes  less  visible,  and  details  of  the 
choroid  may  be  seen.  In  most  eyes,  immediately  around 
the  disk  and  in  the  macula,  the  retinal  layer  holds  so 
much  pigment  that  none  of  the  choroidal  details  are 
visible,  but  toward  the  periphery  of  the  fundus  they  may 
be  studied  in  nearly  all  eyes. 

The  details  of  the  choroid  consist  first  of  the  larg- 
est choroidal  vessels,  which  appear  with  interspaces,  either 
darker  or  lighter,  according  to  the  amount  of  pigment 
deposited  in  the  stroma  of  the  choroid  (see  Fig.  118).  The 
vessels  are  comparatively  broad,  and  form  an  irregular  net- 
work of  rounded  loops  in  contrast  to  the  retinal  vessels, 


88  DETAILS  OF  THE  CHOROID. 

which  are  narrow  and  run  a  comparatively  direct  course 
without  inosculation,  and  bifurcate  at  irregular  intervals, 
the  branches  becoming  progressively  smaller  toward  the 
periphery  of  the  retina. 

In  most  eyes  the  retinal  vessels  are  the  more  distinctly 
seen ;  but  in  eyes  devoid  of  pigment  choroidal  vessels 
may  appear  equally  distinct,  so  that  only  their  size  and 
form  of  distribution  reveal  to  which  system  they  belong. 

With  diminution  of  pigment  the  fundus  becomes 
lighter.  In  some  albino  eyes  the  general  background  is 
a  pink  or  yellowish  white;  against  this  background 
appear  many  large  and  small  vessels,  among  which  it 
becomes  difficult  to  trace  those  belonging  to  the  retina. 
This  general  background  is  the  solera,  revealed  by  the 
transparency  of  the  coats  in  front  of  it,  when  these  are 
devoid  of  pigment. 

The  region  of  the  macula  is  brought  under  inspec- 
tion by  having  the  patient  look  at  the  sight-hole  in  the 
mirror.  This  brings  the  corneal  reflex  a  good  deal  in 
front  of  the  pupil,  and  the  greater  sensitiveness  of  the 
retina  at  this  point  causes  the  pupil  to  contract,  so  that 
without  the  use  of  a  mydriatic  it  is  sometimes  impossible 
to  make  a  thorough  examination  of  this  region.  What- 
ever the  general  pigmentation  of  the  eye,  it  is  greatest  in 
the  region  of  the  macula,  where  the  vessels  of  the  choroid 
are  rarely  traceable. 

The  greater  thickness  of  the  retina  in  this  region  with 
this  darker  background  causes  it  to  be  more  frequently 
visible  here  than  in  other  parts  of  the  eye,  except  above 
and  below  the  optic  disk.  The  distribution  of  retinal 
vessels  in  this  region  is  peculiar  ;  the  principal  trunks  run 
above  and  below  the  macula,  only  as  a  rare  anomaly 
crossing  it.  These  trunks  give  off  branches  which  run 
directly  toward  the  macula  from  all  sides,  and  become 
invisible  by  division.  In  the  macula  the  only  detail  to 
be  recognized  is  the  granular  appearance  due  to  the 
irregular  distribution  of  pigment  in  the  retinal  pigment- 
layer.  This  granular  appearance  exists  throughout  the 
eye,  being  most  noticeable  in  eyes  of  moderate  or  dark 


OPHTHALMOSCOPIC  DIAGNOSIS.  89 

pigmentation,  but  it  is  best  developed  in  this  region  of 
the  macula. 

At  the  center  of  the  macula  is  commonly  found  a  cres- 
cent of  shining  reflex,  marking  the  border  of  the  fovea 
centralis  (see  Fig.  28).  It  varies  in  size  and  shape  with  the 
varying  dimensions  of  that  depression  in  the  retina,  the  cres- 
cent being  a  reflection  from  a  portion  of  the  margin  of  the 
depression.  By  slightly  changing  the  angle  at  which  the 
light  enters  the  eye,  by  change  of  the  direction  of  the 
mirror,  the  part  from  which  the  reflection  is  obtained 
varies ;  sometimes  the  complete  ring  of  reflex  may  be 
seen. 

Retinal  Reflections. — Gleams  of  light,  shifting  or 
vanishing  as  the  position  or  direction  of  the  mirror  is 
slightly  changed,  may  be  perceived  in  various  parts  of 
the  retina.  In  an  eye  with  a  dark  retina  and  choroid 
these  often  resemble  the  reflections  from  the  surface  of 
silk,  and  are  spoken  of  as  the  "  watered  silk"  or  "shotted 
silk "  appearance  of  the  retina.  Sometimes  they  follow 
the  course  of  the  largest  retinal  vessels,  but  often  they 
cross  them  irregularly.  They  are  best  studied  with  a 
mirror  having  a  very  short  focus,  and  with  a  lens  focussed 
for  rays  coming  from  a  little  in  front  of  the  retina. 
With  the  ordinary  ophthalmoscope  mirror  they  are  more 
noticeable  through  the  undilated  pupil  than  after  the  use 
of  a  mydriatic. 

One  of  the  most  regular  of  these  reflections  is  an  oval, 
or  sometimes  circle,  around  the  macula  (see  Plate  I,  1). 
Through  the  undilated  pupil  usually  only  small  portions 
of  this  can  be  seen  at  once,  and  after  the  use  of  a  mydri- 
atic it  often  cannot  be  discovered,  except  with  a  special 
mirror.  Increased  visibility  of  these  reflections  has  been 
regarded  as  an  evidence  of  irritation  or  edema  of  the  retina, 
but  it  must  be  considered  a  rather  indefinite  and  uncertain 
sign  of  such  conditions. 

A  distinct  reflex  concentric  with  the  optic  disk  and  a 
little  to  its  nasal  side,  the  "  Weiss  reflex,"  indicates  swell- 
ing of  the  disk,  and  has  been  considered  an  evidence  of 
progressive  myopia.  It  is  represented  in  Fig.  34. 


90     ABNORMAL  APPEARANCES  OF  THE  RETINA. 

ABNORMAL  APPEARANCES  AND  ANOMALIES  OF  THE 
RETINA. 

Haziness  in  the  retina  interferes  with  the  percep- 
tion of  the  structures  that  lie  back  of  it,  as  the  .stippling 
of  the  pigment-layer,  or  the  network  of  choroidal  vessels, 
and  also  the  parts  of  the  retinal  vessels  that  are  deeply 
buried  in  the  retina.  Where  the  vessels  come  close  to, 
or  lie  upon,  the  anterior  surface  of  the  retina,  however, 
they  will  be  clearly  seen,  being  often  more  distinct  than 
normal,  because  the  gray  of  the  hazy  retina  gives  a 
stronger  contrast  to  the  red  of  the  vessel  than  does  the 
normal  fundus. 

Haziness  in  the  retina  renders  more  marked  or  extends 
beyond  the  normal  limits  the  appearance  of  the  retina  as 
a  gray  veil.  In  proportion  as  it  is  present,  the  red  hue 
of  the  fundus  is  masked  by  the  gray  or  the  green- 
ish or  bluish  color  that  it  causes.  It  may  be  either 
general  or  localized.  In  the  former  case  it  is  most 
pronounced  in  those  regions  where  the  retina  is  thickest. 
In  general,  it  indicates  edematous  swelling  of  the  retina. 

Haziness  of  the  retina  is  seen  in  some  cases  of  eye- 
strain.  It  is  also  likely  to  be  present  after  bruise  of  the 
eyeball,  causing  a  general  disturbance  of  the  coats.  It  is 
an  early  sign  of  albuminuric  retinitis,  one  of  the  distinc- 
tive signs  of  neuroretinitis,  and  is  very  marked  in  the 
retinitis  of  leukemia.  It  is  very  pronounced  and  general 
in  embolism  or  thrombosis  of  the  central  retinal  vessels, 
sometimes  giving  the  fundus  of  the  eye  a  gray  or  white 
appearance  that  shades  off  toward  the  periphery,  and  in 
the  macula  is  interrupted  by  a  very  dark  red  spot  at  the 
fovea.  (Compare  Plate  I,  2,  and  Figs.  116,  117,  and 
119.) 

Hemorrhage  sometimes  occurs  on  the  surface  of  the 
retina,  immediately  adjoining  the  hyaloid  membrane 
separating  it  from  the  vitreous.  Such  a  hemorrhage  may 
be  seen  covering  the  region  of  the  macula  or  in  other 
parts  of  the  eye,  having  a  sharply  defined,  rounded  bor- 
der. Such  subJn/a/oid  lii'inon-hagcs  are  to  be  distinguished 
from  those  occurring  into  the  substance  of  the  retina. 


OPHTHALMOSGOPIC  DIAGNOSIS.  91 

* 

These  latter  generally  lie  in  the  nerve-fiber  layer,  and  the 
blood  composing  them  is  distributed  somewhat  in  the 
direction  taken  by  the  nerve-fibers.  They  have  what  is 
called  a  "  flame-shaped  "  outline,  the  narrower  end  toward 
the  optic  disk  and  the  broader  extremity  from  it,  with 
feathered  edges,  especially  at  its  peripheral  margin  (see 
Plate  I,  2,  II,  8,  and  Figs.  116  and  117). 

Such  hemorrhages  conceal  the  retinal  vessels  that  pass 
across  them. 

Fatty  degeneration,  either  of  the  retina  or  of 
exudate  into  it,  causes  a  patch  of  white,  often  quite  bril- 
liant. Such  white  patches  are  especially  characteristic  of 
the  retinitis  that  attends  chronic  vascular  and  renal  dis- 
ease— albuminuric  retinitis  (Plate  I,  2,  and  Fig.  117). 
In  this  affection  there  are  at  the  macula  points  or  large 
patches  of  white,  arranged  in  lines  radiating  from  the 
center  of  the  macula,  sometimes  in  only  one  direction, 
sometimes  in  all  directions.  The  typical  appearance  is 
seen  before  the  spots  run  together  in  large  irregular 
patches,  when  the  appearance  is  less  characteristic.  In 
the  later  stages,  too,  the  patches  are  less  likely  to  be 
pure  white,  but  have  a  brownish  discoloration.  Some- 
times the  white  patches  of  fatty  degeneration  are  con- 
fined to  the  walls  of  one  or  more  vessels,  causing  the 
vessel  for  a  certain  distance  to  appear  as  a  white  line 
(Plate  I,  1).  Such  an  appearance  indicates  advanced 
degeneration  of  the  vessel-walls,  generally  attended  with 
similar  changes  in  other  vessels  of  the  body.  White 
patches  in  the  retina  have  to  be  distinguished  from  white 
patches  back  of  the  retina,  due  to  exposure  of  the  solera 
through  atrophy  of  intervening  structures. 

Medullated  Nerve-fibers. — In  the  optic  nerve  each 
axis-cylinder  has  its  opaque  medullary  sheath,  but  in  the 
retina  the  sheath  is  lacking.  At  or  behind  the  lamina 
cribrosa  the  sheath  commonly  begins.  If  it  begins  just 
in  front  of  the  lamina  the  nerve-head  is  rendered  opaque 
and  the  lamina  invisible.  Sometimes  a  portion  of  the 
nerve-fibers  have  medullary  sheaths  while  in  the  retina. 
When  a  very  fewr  fibers  are  thus  furnished,  there  results  a 


92  MEDULLATED  NERVE-FIBERS. 

striate  appearance  of  the  retina,  frequently  seen  above  or 
below  the  optic  disk.  When  a  large  number  of  the  fibers 
are  so  covered,  the  result  is  a  large  white  patch  resem- 
bling in  color  the  patches  of  fatty  degeneration  in  the 
retina,  but,  unlike  them,  situated  at  the  upper  or  lower 
margin  of  the  disk  and  extending  in  the  direction  in 
which  the  nerve-fibers  run  (see  Fig.  125). 

In  most  cases  of  the  kind  the  fibers  do  not  keep  the 
sheath  continuously,  but  lose  it  at  the  edge  of  the  optic 
disk,  so  that  the  white  patch  does  not  hide  the  disk  itself 
but  is  confined  to  the  neighboring  retina.  Its  distal  mar- 
gin is  never  abrupt,  some  of  the  fibers  losing  their  sheaths, 
while  others  still  retain  them,  giving  a  gradual  tran- 
sition from  the  white  patch  to  the  normal  red  of  the 
fundus — the  so-called  "  feathered  edge."  It  is  this  edge 
and  the  distribution  of  the  white  patch  that  distinguish 
medullated  nerve-fibers  from  the  sharply  bounded,  white 
patches  of  retinal  degeneration.  In  both  cases  the  retinal 
vessels  may  run  across  the  surface  at  some  points,  and  at 
others  may  be  quite  lost  from  view  in  the  white  opaque 
tissue. 

Changes  in  the  Retinal  Vessels.— Hyperemia 
of  the  retina  is  not  exhibited  by  an  increase  in  the  gen- 
eral red  of  the  fundus  so  much  as  by  the  enlargement  of 
the  individual  retinal  vessels.  By  enlargement  a  greater 
number  become  visible ;  the  principal  branches  are 
noticeably  broadened  as  compared  with  the  size  of  the 
optic  disk;  and  the  vessels,  enlarged  not  only  laterally  but 
also  in  the  direction  of  their  length,  become  more  tortu- 
ous. Their  tortuosity  is  shown,  both  by  their  more  visibly 
wavy  course  and  by  the  fact  that  certain  portions  of  each 
vessel  stand  out  in  front  of  the  retina,  while  other  parts  are 
correspondingly  sunk  beneath  the  surface.  In  the  pres- 
ence of  haziness  of  the  retina  this  makes  a  decided  con- 
trast in  the  clearness  with  which  the  different  parts  of  a 
vessel  are  seen.  This  symptom  must  be  carefully  distin- 
guished from  one  of  the  ophthalmoscopie  appearances  of 
astigmatism.  (Compare  the  appearances  represented  in 


OPHTHALMOSCOPIC  DIAGNOSIS.  93 

Plate  I,  2,  and  in  Plate  II,  8  with  the  appearances  of 
these  plates  seen  through  a  strong  cylindrical  lens.) 

Enlargement  of  the  retinal  vessels  is  commonly 
uniform  unless  the  vessel-walls  are  themselves  diseased, 
when  they  are  liable  to  irregular  dilatations.  In  elderly 
persons  irregularities  in  the  caliber  of  the  retinal  vessels 
are  not  rare.  It  cannot  be  asserted  that  these  vessels 
are  entirely  healthy,  although  sometimes  they  seem  to 
return  to  and  remain  in  a  normal  condition.  Contraction 
of  the  retinal  vessels  is  mostly  seen  in  connection  with 
optic  atrophy.  It  indicates  that  the  atrophy  has  been  due 
to  disease  involving  the  retina.  It  is  commonly  general 
and  uniform,  except  when  arising  from  disease  of  the 
vessel-walls,  or  shortly  after  a  complete  or  almost  com- 
plete interruption  of  the  retinal  circulation,  as  by  embol- 
ism. The  arteries  and  veins  may  be  equally  dilated  or 
contracted,  or  one  set  of  vessels  may  be  more  altered  than 
the  other.  Pressure  at  the  nerve-head,  as  in  glaucoma 
or  optic  neuritis,  tends  to  distend  the  veins  and  diminish 
the  arteries  (see  Figs.  30  and  32).  The  color  of  the 
retinal  vessels  may  be  altered  by  changes  in  the  con- 
stitution of  the  contained  blood.  In  diabetes  it  is  some- 
times impossible  to  distinguish  between  the  arteries  and 
veins.  In  anemia  they  become  paler,  especially  the  veins. 
At  death  the  blood-column  is  seen  to  become  finely  gran- 
ular before  its  movement  ceases. 


CHANGES   IN  THE  OPTIC  DISK. 

Redness. — Most  of  the  eyes  examined  ophthalmos- 
copically  present  disks  that  arc  abnormally  red.  Redness 
of  the  disk  is  liable  to  attend  all  kinds  of  eye-strain  and 
all  ocular  inflammation.  Within  the  normal  limits,  how- 
ever, the  redness  of  the  disk  varies  greatly,  and  its 
apparent  redness  depends  also  on  the  contrast  of  the  color 
of  the  fund  us  around  it.  When  the  fundus  is  dark,  the 
disk  appears  relatively  Avhite  by  contrast,  and  when  the 
surrounding  fundus  is  light,  the  disk  appears  more  nearly 
of  the  same  color. 


94  CHANGES  IN  THE  OPTIC  DISK. 

Only  by  the  extensive  use  of  the  ophthalmoscope,  in- 
cluding examinations  of  normal  eyes,  can  the  observer 
establish  an  approximate  standard  for  the  normal  color 
of  the  disk.  Increased  redness,  if  slight,  does  not  hide 
the  usual  gradations  of  colors  presented  by  the  normal 
disk.  The  temporal  side  and  central  depression  remain 
less  red  than  other  parts ;  but,  if  the  hyperemia  be  very 
great,  these  differences  of  color  are  usually  less  pro- 
nounced. Redness  of  the  disk  includes  a  uniform  altera- 
tion of  hue  from  dilatation  of  invisible  vessels,  and  the 
increase  in  size  and  number  of  visible  vessels.  At  its 
maximum  the  disk  may  have  the  color  of  the  surrounding 
fundus.  The  increased  redness  may  be  limited  to  the 
disk  in  cases  of  optic  neuritis.  In  cases  of  eye-strain, 
however,  it  is  associated  with  hyperemia  of  the  retina  and 
choroid,  more  closely  and  directly  with  the  latter,  because 
the  vessels  which  supply  the  head  of  the  optic  nerve  are 
not  branches  of  the  central  retinal  vessels,  but  branches  of 
the  vessels  that  furnish  the  blood-supply  of  the  choroid. 

The  hyperemia  of  the  disk  arising  from  eye-strain  is 
essentially  similar  to  the  hyperemia  present  in  the  early 
stage  of  serious  organic  disease  of  the  optic  nerve,  in  con- 
nection with  brain-tumor  or  meningitis.  In  later  stages 
of  optic  neuritis  from  brain-disease  the  hyperemia  is  quite 
different.  The  general  pink  flush  that  exists  in  health 
and  is  emphasized  in  early  hyperemia  is  wanting ;  and 
the  alteration  of  color  depends  on  an  increase  in  number, 
with  irregular  dilatation  of  the  smaller  visible  vessels. 
Hyperemia  of  this  character  marks  the  transition  from 
inflammation  of  the  optic  nerve  to  atrophy. 

Opacity  of  the  Nerve -head. — The  normal  varia- 
tions in  the  visibility  of  the  lamina  prevent  it  from  serv- 
ing as  a  test  for  the  exudation  in  the  nerve-head  in  a  large 
proportion  of  cases.  If  from  previous  examination  it  is 
known  that  the  lamina  was  normally  visible,  as  in  Fig.  29, 
the  obscuration  of  it  will  be  one  of  the  first  signs  of 
opacity  of  the  normally  transparent  tissue  in  the  nerve- 
head.  Later  may  come  obscuration  of  the  large  vessels, 
the  disk-margin,  and  the  choroidal  ring. 


OPHTHALMOSCOPIC  DIAGNOSIS. 


95 


The  upper  and  lower  margins  of  the  disk  are  usually 
partially  obscured  by  the  nerve-fibers,  the  bulk  of  which 
pass  off  in  these  directions.  Such  obscuration  is  by 
striations,  while  that  due  to  swelling  of  the  tissue  is  by  a 
general  haziness. 

The  degree  to  which  the  different  structures  are  ob- 
scured will  depend  on  the  amount  of  exudation  into  the 
nerve-head.  In  some  cases  it  amounts  to  complete  hid- 
ing of  the  nerve-outline  beneath  a  reddish-gray  swelling, 
which  can  only  be  certainly  recognized  as  the  site  of  the 


FIG.  29. 


FIG.  30. 


FIG.  29.— The  normal  optic  disk,  shown  in  section  below,  in  contrast  with 
FIG.  30,  which  shows  the  ophthalmoscopic  appearances  and  section  of  the 
optic  nerve-head  in  optic  neuritis. 

optic  disk  by  the  divergence  of  the  retinal  vessels  from 
it  (see  Fig.  30).  Such  a  condition  is  reached  very 
rarely  in  the  neuritis,  due  to  eye-strain.  It  indicates 
rather  that  the  changes  in  the  nerve-head  are  due,  either 
to  general  disease,  such  as  Bright' s  disease  or  pernicious 
anemia,  or  to  organic  cerebral  disease.  In  a  very  few 
cases  some  such  appearance  may  be  presented  as  an 
anomaly. 

Swelling  of  the  Disk. — Great  opacity  and  hypere- 


96  SWELLING   OF  THE  DISK. 

raia  only  occur  with  swelling.  The  swelling  is  shown  by 
the  altered  contour  of  the  vessels,  and  particularly  by  the 
difference  of  their  refraction  at  the  center  of  the  disk, 
from  that  of  the  neighboring  fundus.  This  is  to  be 
estimated  with  the  ophthalmoscope  by  the  method  given 
in  Chapter  VI.  First,  the  refraction  is  to  be  measured 
of  the  most  prominent,  most  hyperopic,  or  least  myopic 
details  of  the  nerve-head.  Then  the  refraction  of  the 
adjoining  portion  of  the  fundus  which  appears  most 
nearly  normal  is  to  be  ascertained.  The  difference 
between  the  two  gives  the  height  of  the  swelling. 

It  is  to  be  borne  in  mind  that  in  normal  eyes  there  are 
variations  in  refraction  in  different  parts  of  the  optic  disk, 
aside  from  the  physiological  cup.  One  may  find  a  differ- 
ence of  one  diopter  or  more  between  the  temporal  and 
the  nasal  sides  of  the  normal  disk,  the  latter  being  usually 
the  more  hyperopic.  In  some  eyes,  too,  the  nerve-head 
normally  projects  in  front  of  the  surrounding  fundus. 

Redness,  opacity,  and  swelling  are  signs  of  inflamma- 
tion of  the  optic  nerve-head,  whether  from  eye-strain, 
brain  disease,  or  other  causes. 

Pallor  of  the  Optic  Disk. — The  variations  of  the 
color  of  the  optic  disk  in  health  make  it  always  difficult 
to  say  when  it  is  abnormally  pale.  The  strictly  normal 
disk  is  paler  than  the  great  majority  of  those  examined. 
Paleness  of  the  disk  indicates  optic  atrophy,  and  some- 
times other  signs  of  atrophy  must  be  sought  to  decide  if 
the  disk  is  abnormally  pale.  The  slightest  pallor  of  the 
disk  is  a  diminution  of  the  pink  blush,  from  narrowing  of 
invisible  vessels.  With  greater  change  the  number  of 
small  visible  vessels  will  be  found  reduced.  In  severe 
cases,  all  of  the  small  vessels  become  invisible,  and  only 
the  larger  branches  of  the  central  retinal  vessels  can  be 
seen. 

These  retinal  vessels  may  either  remain  of  normal  size, 
as  in  primary  optic  atrophy  or  atrophy  from  disease  of 
the  optic  tracts,  as  illustrated  in  Fig.  31  ;  they  may  be 
somewhat  enlarged,  as  in  the  earliest  stages  of  postneuritic 
atrophy ;  or  they  may  be  diminished,  as  usually  in  the 


OPHTHALMOSCOPIC  DIAGNOSIS. 


97 


later  stages  of  postneuritic  atrophy,  and  in  optic  atrophy 
due  to  diseases  of  the  disk,  retina,  or  choroid,  or  of  the 
vessels  themselves  (see  Plate  II,  9). 

The  color  of  the  optic  disk  does  not  depend  solely  upon 
its  blood-supply.  In  some  cases  of  optic  atrophy  the  disk 
is  dead  white,  in  others  more  distinctly  gray,  bluish,  or 
even  decidedly  greenish,  as  seen  by  a  yellow  light.  These 
variations  depend  on  the  original  color  of  the  disk,  and 
on  the  amount  and  character  of  the  exudation  into  the 
nerve-head,  during  the  process  that  has  preceded  the 
atrophy  (see  Plate  II,  9  and  10). 

Cupping  of  the  Disk. — Variations  in  the  normal 
level  of  the  disk-surface  and  in  the  size  and  shape  of  the 
physiological  cup  (Fig.  29)  make  it  always  difficult  to 
determine  the  beginning  of  pathological  cupping  of  the 
disk.  The  most  constant  distinction  between  the  normal 


FKJ.  31. 


FIG.  32. 


FIG.  31  shows  disk  in  optic  atrophy  with  broader  shallow  depression  than 
in  Fig.  29,  and  in  contrast  with  PIG.  3'J.  which  shows  the  oplithaliuobcopic 
appearances  and  section  of  the  glaucomatous  excavation. 

and  the  pathological  cup  is  that  the  latter  extends  to  the 
disk-margin,  while  the  former  does  not.  But  in  cases  of 
early  glaucoma  or  atrophy,  the  cupping  may  not  yet  have 

7 


98  CUPPING   OF  THE  OPTIC  DISK. 

reached  quite  to  the  margin,  and  in  rare  cases  the  cup 
extends  to  the  disk-margin,  although  vision  and  the  visual 
field  are  normal. 

A  broad  shallow  depression  with  sloping  sides,  saucer- 
shaped  (see  Fig.  31),  is  to  be  regarded  as  due  to  parenchy- 
matous  or  interstitial  changes  in  the  nerve-head.  A  cup 
with  abrupt  edges,  sometimes  overhanging,  as  illustrated 
in  Fig.  32,  is  to  be  regarded  as  due  to  intra-ocular  press- 
ure ;  generally  to  abnormally  high  intra-ocular  tension — 
glaucoma. 

The  existence  and  the  extent  of  the  cup  of  optic  atrophy 
are  ascertained  by  the  measurement  of  refraction  at  its 
center  and  margins.  The  glaucoma  cup  presents  a  more 
striking  appearance.  The  retinal  vessels  appear  at  the 
bottom  of  it,  pass  on  to  the  sides  of  the  cup,  often  entirely 
out  of  sight,  and  climbing  over  the  margin  of  the  cup, 
reappear  in  a  new  position  quite  disconnected,  apparently, 
from  the  one  they  occupied  at  the  bottom  of  the  cup. 
They  therefore  seem  to  have  a  new,  hook-like  beginning 
at  the  disk-margin,  the  hook  being  the  curve  of  the  vessel 
out  of  the  cup  to  the  general  surface  of  the  fundus.  These 
hooks,  presenting  a  greater  depth  of  blood  to  be  looked 
through,  appear  darker  than  the  other  parts  of  the  vessels. 
The  normal  optic  nerve  as  it  enters  the  sclerotic  becomes 
smaller,  each  nerve-fiber  losing  its  medullary  sheath. 
On  this  account  when  the  cup  extends  quite  to  the  nerve- 
margin,  it  is  larger  below  the  surface  of  the  choroid  than 
at  that  point.  It  is  what  is  called  "kettle-shaped,"  so 
that  its  margins  overhang.  The  optic  nerve  enters  the 
eye  from  the  nasal  side  and  faces  the  center  of  the  eye- 
ball, not  the  pupil.  Hence,  without  any  overhanging 
the  nasal  side  of  the  cup  would  be  invisible,  while  the 
temporal  side  would  still  be  seen. 

The  depth  of  the  pathological  cup  is  of  little  value  for 
prognosis.  It  depends  largely  upon  the  extent  of  the 
physiological  cup  previously  present,  and  in  glaucoma 
more  on  the  duration  of  the  process  than  on  the  malig- 
nancy of  the  case. 

Anomalies  of  the  Optic  Nerve.— Sometimes  the 


OPHTHALMOSCOPIC  DIAGNOSIS.  99 

site  of  the  optic  disk  is  occupied  by  a  cavity  which  may 
be  broader  and  deeper  than  the  largest  glaucoma  cup, 
along  the  side  of  which  the  normal  amount  of  nerve-tissue 
may  make  its  way  to  the  retina,  securing  full  vision  and 
a  good  field ;  or  nerve-tissue  may  be  largely  or  entirely 
absent,  and  the  sight  correspondingly  defective.  This 
condition  is  known  as  coloboma  of  the  optic  nerve.  The 
visible  cavity  sometimes  extends  a  considerable  distance 
back  of  the  sclera  and  may  vary  greatly  in  size.  It  may 
be  associated  with  coloboma  of  the  choroid  or  exist  alone. 

PIGMENTATION. 

Pigmentation  of  the  optic  nerve  is  not  rare.  The 
pigment  appears  as  one  or  more  black  blotches,  like  an 
irregular  ink-spot  on  the  disk.  In  rarer  cases  a  pigmen- 
tation, apparently  continuous  with  that  of  the  normal 
choroid  and  pigment  coat  of  the  retina,  seems  to  cover  a 
portion  of  the  disk  (see  Plate  II,  5). 

Pigment-deposits  in  the  General  Fundus. — 
These  are  dark  brown  or  black  in  color,  and  of  irregular 
shapes.-  They  must  be  distinguished  from  opacities  in 
the  media.  This  is  done  easily  enough  when  the  eye  is 
steady,  and  they  are  clearly  focussed,  but  it  is  sometimes 
difficult  when  only  glimpses  of  a  dark  object  are  caught 
during  ocular  movements.  They  are  located  either  in 
the  retina  or  choroid. 

Pigment -deposits  in  the  Retina. — In  the  retina 
.they  sometimes  overlie  the  branches  of  the  retinal  vessels 
or  enclose  the  vessel  like  a  sheath.  Sometimes  the  vessel 
around  or  along  which  the  pigment-patch  is  developed  is 
too  small  to  be  visible,  or  disappears  in  the  course  of 
later  degenerative  changes,  the  pigment-spot  retaining 
the  branched  shape  of  the  vessel.  Other  spots  have  the 
form  of  a  central  lens-shaped  body  with  radiating 
branches,  somewhat  the  shape  of  a  "  bone-corpuscle." 
These  are  the  typical  forms  of  retinal  pigment-deposits. 
They  are  illustrated  in  Fig.  118. 

A  striking   form  of  retinal   pigment  presents  a  large 


100  PIGMENT  DEPOSITS  IN  THE  RETINA. 

area  or  areas  of  black  or  very  dark  pigment,  giving,  at 
first  glance,  the  impression  of  very  serious  disease,  but  it 
shows  no  disturbance  of  the  choroidal  tissue,  and  is  com- 
patible with  full  vision.  Another  anomaly  consists  of 
dots  of  dark  brown  or  black  occurring  singly  or  in  groups 
upon  a  background  of  normal  fundus. 

Choroidal  Pigment-changes. — In  the  choroid  the 
patches  of  pigment  are  rounded  or  irregular  in  shape, 
and  associated  with  more  or  less  choroidal  atrophy.  Their 
most  common  seat  is  in  the  region  immediately  around 
the  disk.  Normally,  outside  of  the  disk-margin  is  gener- 
ally found  a  ring  of  pigmentation  darker  than  that  of  the 
general  fundus,  called  choroidal  ring  (see  Plates  I  and  1 1 
and  Fig.  31).  This  varies  in  width  from  a  mere  line  to 
one-third  or  one-half  that  of  the  disk.  It  is  sometimes 
uniform  throughout,  but  more  frequently  broader  in  one 
direction  than  in  others.  In  the  majority  of  eyes  the 
pigmentation  of  the  ring  is  quite  irregular.  At  some 
points  the  pigment  is  heaped  up  in  black  masses ;  at 
others  it  is  partly  or  entirely  removed  with  more  or 
less  complete  atrophy  of  the  choroid.  AVhile  such  irregu- 


FIG.  33.  FIG.  154. 


FIG.  33.— Myopic  crescent,  early  stage  ;  atrophy  of  choroid  incomplete. 

FIG.  84.— Myopic  crescent  more  advanced.  The  atrophy  of  the  original  cres- 
cent is  now  complete,  and  a  larger  crescent  of  incomplete  atrophy  has  formed, 
and  a  crescent  of  pigment-disturbance  beyond  that.  The  disk  ha*  also  Income 
more  oblique,  and  therefore,  apparently  narrower.  On  the  right  is  seen  the 
curved  reflex  of  Weiss. 

larities  may  be  normal,  they  denote  in  a  large  proportion 
of  cases,  as  in  that  represented  in  Fig.  33,  past  eye-strain, 
with  hyperrmia  of  the  part  succeeded  by  atrophy.  The 
extension  of  the  atrophy  and  the  pushing  before  it  of 


OPHTHALMOSCOPIC  DIAGNOSIS.  101 

irregular  pigmentation,  usually  to  the  temporal  side  of 
the  disk,  give  the  atrophie  crescent  of  myopia  (see  Figs. 
33  and  34).  Sometimes  the  area  of  this  crescent  is 
entirely  white  or  yellowish  white,  except  where  the 
retinal  vessels  cross  it ;  in  other  cases  it  shows  irregular 
pigment-patches. 

Pigment-blotches  at  the  macula  result  from  in- 
flammation of  the  choroid,  or  perhaps  hemorrhages. 
Multiple  patches  of  pigment-deposit  with  choroidal 
atrophy,  whether  few  or  many,  indicate  disseminated 
choroiditis  (see  Fig.  110).  Where  numerous,  they  are 
frequently  confluent,  forming  large  areas.  The  pigment- 
deposit  marks  a  late  stage  of  choroiditis.  During  the 
early  stages  there  is  no  increase  of  pigment ;  and  when 
the  deposit  becomes  entirely  stationary,  it  is  probable 
that  the  morbid  process  has  run  its  course,  and  that 
no  further  change  will  occur. 

Spots  with  rounded  or  oval  outline,  either  discrete  or 
confluent,  may  be  indicative  of  syphilis,  but  cannot  be 
regarded  as  pathognomonic.  Sometimes  choroidal  changes 
accompany  the  bone-corpuscle  pigment-patches  character- 
istic of  retinitis  pigmentosa;  this  association  usually  indi- 
cates a  form  of  disease  due  to  acquired  syphilis. 

CHOROIDAL  EXUDATE  AND  CHOROIDAL  ATROPHY. 

A  light  spot  in  the  fundus  is  known  to  be  due  to  lesions 
lying  back  of  the  retina,  when  the  retinal  vessels  pass 
across  it  without  being  rendered  less  distinct,  or  when 
choroidal  vessels  are  seen  in  it.  Yellowish  or  orange- 
colored  spots,  generally  slightly  swollen,  sometimes  sur- 
rounded by  a  darker  red  than  is  normal  to  the  fundus, 
indicate  localized  exudation  into  the  choroid.  Very  acute 
chofoidal  exudation  is  usually  attended  with  considerable 
haziness  of  the  retina  and  vitreous  in  front  of  it ;  where 
the  choroidal  condition  is  not  thus  veiled,  it  is  probably 
somewhat  chronic. 

From  the  yellowish  indefinite  discoloration  of  the 
choroidal  exudation  there  is,  with  the  progress  of  the 


102         CHOROIDAL  EXUDATE  AND  ATROPHY. 

case,  the  gradual  passing  over  into  the  whiter,  but  still 
somewhat  yellow,  patch  of  atrophy.  As  the  transition 
occurs,  the  swelling  disappears,  and  usually  along  the 
margin  of  the  spot  pigment-deposits  become  evident. 

Primary  atrophy,  or  atrophy  without  swelling  of  the 
choroid,  leads  first  to  a  diminution  of  the  fundus  red ; 
then  the  larger  choroidal  vessels  become  visible.  Later, 
these  too  undergo  contraction,  and  may  also  entirely  dis- 
appear. There  remains  then  only  the  white  area  of  sclera, 
more  or  less  discolored  by  pigment,  over  which  may  pass 
the  retinal  or  some  of  the  largest  choroidal  vessels.  As 
compared  with  the  color  of  the  normal  disk,  complete 
choroidal  atrophy  is  decidedly  whiter ;  but  it  never  pre- 
sents the  gleaming  white  appearance  of  medullated  nerve- 
fibers,  or  fatty  degeneration  of  the  retina  in  albuminuric 
retinitis. 

The  "Myopic"  Crescent. — The  commonest  seat 
of  choroidal  atrophy  is  to  the  temporal  side  of  the  disk, 
where  it  may  be  seen  in  many  cases  of  severe  eye-strain, 
being  most  largely  developed  in  cases  of  progressive 
myopia.  Such  an  atrophy  starts  first  as  a  yellow  crescent 
lying  on  the  temporal  side  of  the  disk,  which  broadens 
either  by  gradual  extension,  or  by  the  successive  appear- 
ance of  similar  crescents  of  atrophy  to  the  temporal  side. 
If  these  proceed  far  enough,  there  results  a  somewhat  tri- 
angular area  of  yellowish  white,  with  its  base  at  the  disk 
and  its  apex  toward  the  macula,  called  a  conus  (see  Fig. 
63).  With  its  extension  in  this  direction  the  atrophy  is 
apt  also  to  encircle  the  disk,  and  gradually  extend  in 
other  directions. 

Other  I/ocal  I/esions. — Less  frequently  choroidal 
exudate  or  atrophy  is  found  in  other  parts  of  the  fundus, 
being  most  serious  in  the  region  of  the  macula,  which 
should  be  carefully  searched  for  them.  Such  areas  may 
also  be  found  confined  to  the  periphery  of  the  fundus. 

One  or  more  crescentic  areas,  approximately  concentric 
with  the  optic  disk,  but  quite  removed  from  it,  ornerally 
in  the  direction  of  the  macula,  sometimes  even  beyond  it, 
are  characteristic  of  so-called  rupture  of  the  choroid  (see 


OPHTHALMOSCOPIC  DIAGNOSIS.  103 

Fig.  148).  They  are  usually  attended  with  marked  altera- 
tions of  other  parts  of  the  fundus.  Occasionally  there 
occur  sharply  defined,  rounded  areas,  or  a  similar  white 
area  stretches  from  some  point  below  the  disk  or  even 
from  above  the  disk  forward  to  the  lower  periphery  of 
the  fundus.  This  is  coloboma  of  the  choroid  (see  Fig. 
115). 

BIBLIOGRAPHY. 

Text-book  of  Ophthalmoscopy.  Vol.  i.,  The  Normal  Eye  ;  274  pp. 
Vol.  ii.,  Diseases  of  the  Retina,  Optic  Nerve,  and  Choroid;  260 
pp.  by  E.  G.  Loring.  D.  A  ppleton  &  Co.,  New  York. 

The  Fundus  Oculi  with  an  Ophthalmoscopic  Atlas,  228  pp.,  47  col- 
ored plates,  by  W.  Adams  Frost.  Young  J.  Pentland,  Edin- 
burgh. Macmillan  &  Co.,  New  York. 

Atlas  of  Ophthalmoscopy,  O.  Haab.  Bailliere,  Tindall  &  Cox,  Lon- 
don ;  Win.  Wood  &  Co.,  New  York. 

The  Ophthalmoscope  and  Its  Use,  The  Normal  Eye-ground,  B.  A. 
Randall.  "  American  Text-book." 

The  Light  Streak  on  the  Retinal  Vessels.  J.  B.  Story,  "  Ophthal- 
mic Review,"  Apr.,  1892.  A.  E.  Davis,  "Ophthalmic  Review," 
Aug.,  1892. 

Location  of  Opacities  by  the  Corneal  Reflex,  Edward  Jackson. 
"Ophthal.  Record,'' Feb..  1897. 

Use  of  Direct  Sunlight  in  Ophthalmoscopic  Examinations,  E.  Jack- 
son. "Ophthalmic  Review,"  June,  1899. 

Medical  Ophthalmoscopy,  375  pp.,  Sir  W.  R.  Gowers.  J.  &  A. 
Churchill,  London. 


CHAPTER   V. 

REFRACTION;     PRISMS    AND    LENSES,    AND    THEIR 
STRENGTH  AND  NUMBERING. 

UPON  the  free  surface  of  the  body  light  falls  from  each 
point  of  every  visible  object,  and  were  the  sensitive 
retina  so  placed  as  to  receive  this  light,  each  point  of  the 
retina  would  be  impressed  by  light  from  every  luminous 
point  before  it.  Each  point  of  the  retina  Avould  then 
receive  an  impression  similar  to  that  made  upon  every 
other  point,  giving  only  a  general  perception  of  light. 


104 


IMPORTANCE  OF  REFRACTION. 


For  complete  vision  each  luminous  point  must  make 
its  distinct  impression  on  a  single  point  of  the  retina,  and 
through  it  upon  a  single  nerve-cell  or  group  of  nerve- 
cells  in  the  brain.  To  accomplish  this,  the  tight  falling  on 
the  retina  must  be  assorted  or  focussed.  To  support  the 
retina  so  that  it  shall  properly  receive  assorted  light  is  the 
function  of  the  eyeball.  The  assorting  is  eifected  in  the 
human  eye  by  refraction,  and  the  whole  function  of  the 
eyeball  being  to  support  and  protect  the  retina  so  that  it  may 
receive  properly  refracted  rays,  the  refraction  of  the  eye 
is  of  primary  importance  in  its  physiology  and  pathology. 

REFRACTION  OF  LIGHT. 

Light  consists  of  successive  waves  passing  from  each 
luminous  point  in  all  directions,  like  the  waves  which 
arise  when  a  stone  is  dropped  in  still  water. 

The  direction  of  wave-movement  is  always  perpendicular 
to  the  wave-crest  or  wave-front. 

Waves  of  light  travel  faster  in  some  substances  than  in 
others.  Upon  these  two  facts  depend  all  the  phenomena 
of  refraction. 

In  Fig.  35  the  circles  represent  wave-fronts  of  light 
from  a  luminous  point,  A.  The  radiating  lines  perpen- 
dicular to  the  wave-fronts  represent  the  directions  in 


A--V 


c1 


/-/y. 


D' 

FIG.  35.— Waves  of  light  passing  off  from  a  luminous  point,  and  rays  along 
which  the  light  passes. 

which  the  different  parts  of  these  wave-fronts  are  moving. 
They  are  called  u  raffs  "  of  light.     Close  to  the  point  from 


REFRACTION  OF  LIGHT.  105 

which  the  light  emanates,  the  rays  included  in  a  given 
space  as  CD  will  be  very  divergent.  At  a  greater  dis- 
tance the  rays  included  in  this  same  space  C'  D'  will  be 
less  divergent.  As  the  waves  pass  on,  the  included  part 
of  a  wave-front  becomes  more  and  more  nearly  straight, 
and  at  an  infinite  distance  the  rays  included  in  a  certain 
space  would  be  parallel,  and  the  parts  of  the  wave-fronts 
not  circular  but  straight.  Here  we  have  only  to  consider 
the  rays  and  parts  of  the  wave-fronts  that  enter  the  eye 
through  the  pupil,  usually  from'  3  to  6  mm.  in  diameter. 
It  is  customary  to  speak  of  rays  that  come  from  20  feet 
and  only  diverge  the  width  of  the  pupil  as  parallel  rays. 
This  is  not  strictly  correct ;  but  it  is  convenient,  and 
unless  otherwise  stated,  they  will  be  so  considered  here. 

Transparent  substances  are  called  dioptric  media. 
Of  the  dioptric  media  we  have  to  consider,  light  moves 
most  rapidly  through  air.  If  we  take  the  time  it  requires 
for  light  to  travel  a  given  distance  in  air  as  1,  the  times 
required  to  travel  the  same  distance  in  other  transparent 
substances  are  indicated  as  follows  : 

Water,  the  cornea,  aqueous  or  vitreous  humors,  .    .    .  1.33 

The  crystalline  lens, 1.45 

Crown  glass,  used  for  spectacles, 1.53  to  1.54 

Rock  crystal,  "pebble," 1.56 

Flint  glass, 1.57  to  1.70 

Diamond, 2.25  to  2.60 

Such  a  number  indicating  the  relative  length  of  time 
required  for  light  to  travel  a  unit  of  distance  in  a  given 
substance  is  its  index  of  refraction. 

When  light  passes  from  a  substance  having  one  index 
of  refraction  into  a  substance  having  another  index  of 
refraction,  its  rate  of  movement  undergoes  a  change  cor- 
responding to  the  difference  between  the  two.  On  account 
of  slower  movement  the  successive  waves  will  be  closer 
together  in  the  medium  having  the  higher  index,  and  on 
account  of  faster  movement  they  will  be  farther  apart  in 
the  medium  having  the  lower  index  of  refraction.  What 
occurs  when  the  wave-fronts  correspond  to  the  surface 


106 


RETARDING   OF  LIGHT   WAVES. 


separating  the  media  and  the  rays  fall  perpendicular  to 
that  surface,  is  shown  in  Fig.  36. 


G 


FIG.  36.— Waves  of  light  passing  from  air  into  glass,  retarded,  but  their 
direction  not  altered. 

Within  the  substance  G  (glass)  having  the  higher  index, 
the  wave-fronts  are  closer  together,  but  have  the  same 
direction,  and  the  rays  perpendicular  to  them  have  the 
same  direction,  as  in  the  substance  A  (air).  This  is  true 
whether  the  waves  be  passing  from  A  to  G  or  from  G 
to  A. 

When  the  wave-fronts  and  rays  strike  obliquely  the 


B' 


-P 

FIG.  37.— Refraction  of  light  when  the  waves  pass  obliquely  from  the  air  into 
glass,  illustrating  the  "  law  of  the  sines." 

surface  separating  the  dioptric  media,  the  effect  is  different, 
as  illustrated  in  Fig.  37. 


REFRACTION  OF  LIGHT.  107 

When  a  wave-front  travelling  through  air  reaches  the 
position  B  B',  a  portion  at  B  passes  into  the  second 
medium,  which  we  will  take  as  glass,  and  its  movement 
is  immediately  retarded,  so  that  while  B'  travels  to  C",  B 
only  travels  to  C,  a  distance  the  reciprocal  of  the  index 
of  refraction  of  the  glass,  j^«  The  eifect  of  this  is 
that  when  the  wave  has  reached  C  C1,  its  direction  has 
essentially  changed ;  since  light  moves  along  lines  per- 
pendicular to  the  wave-fronts,  its  movement  will  now  be 
in  rays  perpendicular  to  CC1,  making  a  decided  angle 
with  the  rays  perpendicular  to  BB'.  By  passing  ob- 
liquely from  one  dioptric  medium  into  the  other,  the 
direction  of  the  rays  of  light  has  been  changed. 

The  same  thing  occurs  if  the  light  passes  from  the  glass 
into  the  air,  the  wave-front  going  from  CC'  to  BB'.  In 
either  case  the  direction  of  the  ray  is  equally  bent  at  the 
surface  separating  the  two  media.  But,  in  passing  toward 
the  medium  having  the  higher  index,  called  the  more 
refracting,  the  ray  is  bent  toward  a  perpendicular  PP'  of 
the  bounding  surface  ;  and  in  passing  toward  the  medium 
with  a  lower  index  of  refraction,  called  the  less  refracting 
medium,  the  ray  is  bent  from  the  perpendicular.  The 
amount  of  this  bending  depends  on  the  difference  of  the 
indexes  of  refraction  and  on  the  obliquity  of  the  wave- 
front  to  the  bounding  surface.  The  more  the  wave  is 
retarded  by  the  glass  or  the  farther  the  wave  at  B  has  to 
travel  in  the  glass  while  the  part  at  B'  is  still  in  air,  the 
greater  will  be  the  change  of  direction. 

If  PP'  be  drawn  perpendicular  to  the  bounding  surface 
at  B,  the  angle  ABP'  between  the  perpendicular  and  AB, 
the  direction  of  the  incident  ray,  is  called  the  angle  of 
incidence;  and  CBP,  the  angle  between  the  same  per- 
pendicular and  the  direction  of  the  ray  after  it  has  been 
refracted,  is  called  the  angle  of  refraction.  The  relation 
of  one  of  these  angles  to  the  other  is  illustrated  iu  the 
triangles  BB'C  and  BCC',  the  angle  B'BC'  being  equal 
to  the  angle  of  incidence,  ABP'  (because  their  sides  are 
mutually  perpendicular),  and  the  angle  BC'C  being  equal 


108  LAW  OF  THE  SINES. 

to  the  angle  of  refraction  PB C  (because  their  sides  are 
mutually  perpendicular).  But  these  two  triangles  BB'C? 
and  BC'C  are  right-angled  triangles  with  a  common  side 
BC',  which  may  be  taken  as  radius  or  1,  for  both  triangles. 
By  the  common  relation  of  the  sides  of  a  right-angled 
triangle  to  the  sine  of  the  opposite  angle  we  have 

EG' :  1  :  :  B'C' :  sin  B'BC',  the  angle  of  incidence. 
BO  :  I  :  :  BC  :  sin  BC'C,  the  angle  of  refraction. 
or  B'C':  sin  B'BC' :  :BC:  sin  BC'C. 
sin  B'BO  :  sin  BC'C:  :B'C':  BC. 

That  is,  the  sine  of  the  angle  of  refraction  is  to  the  sine 
of  the  angle  of  incidence,  as  the  index  of  refraction  of  the 
substance  from  which  the  light  passes  is  to  the  index  of 
refraction  of  the  substance  to  which  the  light  passes.  This 
is  called  the  law  of  the  sines ;  and,  as  is  shown  above, 
depends  simply  on  the  fact  that  light  moves  perpendicular 
to  its  wave-fronts. 

When  light  passes  through  a  plate  of  glass  with  parallel 
sides,  if  it  enter  the  glass  in  such  a  way  that  the  rays  are 
perpendicular  to  the  surface,  their  direction  will  not  be 
changed  either  on  entering  or  leaving  the  glass.  The 
whole  wave-front  entering  the  glass  at  the  same  time  is 
equally  retarded,  and  keeps  its  original  direction,  merely 
moving  through  the  glass  more  slowly ;  and  on  reaching 
the  other  surface  it  all  passes  out  at  once,  and  has  its  move- 
ment equally  accelerated  in  all  parts  (see  Fig.  36).  If  a 
ray  of  light  fall  obliquely  upon  the  surface  of  the  glass, 
it  will  be  refracted  toward  the  perpendicular  on  entering 
the  glass,  but  equally  from  the  perpendicular  on  leaving 
it  if  the  two  surfaces  of  the  glass  are  parallel ;  so  that  the 
direction  of  the  ray  after  leaving  the  glass  is  parallel  to 
its  direction  before  entering  it.  This  is  shown  in  Fig. 
38,  the  ray  AB  being  refracted  toward  the  perpendicular 
on  entering  the  glass  at  B,  and  being  refracted  from  the 
perpendicular  on  leaving  the  glass  at  C,  so  that  the  direc- 
tion of  CD  will  be  parallel  to  AB. 

When,  however,  light  passes  through  a  piece  of  glass, 


REFRACTION  OF  LIGHT. 


109 


the  sides  of  which  are  not  parallel,  but  inclined  toward 
one  another,  the  portion  of  each  light- wave  that  has  to 
pass  through  the  thicker  part  of  the  glass  is  more  retarded 


B. 


FIG.  38.— 
of  wa 


—Refraction  of  light  by  a  plate  of  glass  with  parallel  sides.     Direction 
es  and  rays  altered  on  entering  the  glass,  and  restored  on  passing  out. 


than  the  portions  of  the  wave  which  pass  through  the 
thinner  portions  of  the  glass ;  and,  on  this  account  the 
direction  of  the  wave-fronts,  and  the  direction  of  the  rays 


FIG.  39.— Refraction  of  light  by  a  prism.    Direction  of  waves  and  rays  altered 
on  entering  the  prism,  and  still  further  altered  on  leaving  it. 

perpendicular  to  it,  are  permanently  changed.  This 
change  is  illustrated  in  Fig.  39,  in  which  the  wave-fronts 
are  changed  from  their  original  direction  on  entering  the 
glass,  and  swung  around  still  further  on  leaving  it,  CD 
having  an  essentially  different  direction  from  ylT?.  In  all 
cases  the  part  of  the  wave-front  which  goes  through  the 
thicker  portion  of  the  glass  is  more  retarded,  so  that  the 
ray  is  bent  toward  that  part  of  the  glass. 


110  PRISMS. 


PRISMS. 

A  piece  of  glass  bounded  by  plane  surfaces  which  are 
inclined  toward  each  other  is  called  a  prism.  The  line 
in  which  these  plane  surfaces  intersect  is  the  edge  or  apex 
of  the  prism.  The  thickest  portion  is  the  base  of  the 
prism.  The  angle  between  the  two  intersecting  surfaces 
is  called  the  refracting  angle  of  the  prism. 

From  what  has  been  demonstrated  it  is  evident  that 
if  light  passes  through  a  prism  it  will  be  turned  toward 
the  base,  and  after  leaving  the  prism  will  proceed  as 
though  from  A'  (Fig.  39),  more  in  the  direction  of  the  apex. 
The  refracting  power  of  the  prism  (its  ability  to  turn  rays 
of  light  from  their  original  direction)  depends  first  on  the 
index  of  refraction  of  the  glass  of  which  the  prism  is  com- 
posed as  compared  with  that  of  the  air  around  the  prism. 
This  determines  the  retardation  of  the  wave  while  in  the 
prism.  Second,  it  depends  on  the  shape  of  the  prism, 
which  determines  how  much  longer  one  part  of  a  light- 
wave is  subjected  to  the  retarding  influence  of  the  glass 
than  another  part. 

The  higher  the  index  of  refraction  of  the  prism  and  the 
larger  its  refracting  angle,  the  "  stronger "  the  prism. 
The  effect  of  the  prism  also  depends  on  its  obliquity 
to  the  light.  If  the  light  enters  or  leaves  the  prism 
very  obliquely,  it  acts  as  a  stronger  prism.  This  can 
be  demonstrated  thus :  Take  a  weak  prism  from  the 
trial  case,  hold  it  so  as  to  be  nearly  perpendicular  to  the 
line  of  sight,  and  note  the  displacement  it  seems  to  cause 
in  a  line,  like  a  window-sash.  Then  rotate  the  prism 
about  its  base  or  apex,  and  note  how  the  displacement  in- 
creases as  the  surfaces  become  oblique.  The  effect  of  a 
prism  also  varies  with  the  color  of  the  light  that  it  refracts. 
A  prism  of  a  given  strength  refracts  the  blue  and  the 
violet  rays  more  than  the  red.  The  difference  of  effect  of 
the  same  prism  on  light  of  different  colors,  causes  the  dis- 
persion of  white  light  into  the  prismatic  colors  or  spec- 
trum. This  power  of  dispersion  differs  with  different  sub- 
stances, but  not  in  proportion  to  the  index  of  refraction. 


REFRACTION  BY  PRISMS.  Ill 

Dispersion  is  much  less  through  the  crown  glass,  ordin- 
arily used  for  spectacles,  than  it  is  for  the  heavier,  softer 
"  flint "  glass,  employed  in  some  other  optical  instru- 
ments. 

Numbering  of  Prisms. — Formerly  prisms  were 
numbered  by  the  refracting  angle — that  is,  a  prism  hav- 
ing surfaces  which  met  at  an  angle  of  10  degrees  was 
called  a  No.  10  prism.  This  was  its  number  whatever 
the  kind  of  glass  from  which  it  was  made,  so  that  prisms 
having  the  same  number  would  vary  according  to  the 
index  of  refraction  of  the  glass  of  which  they  were  com- 
posed. In  1887  the  writer  suggested  that  they  should 
be  numbered  according  to  the  effect  they  produce  on  the 
light  passing  through  them,  according  to  their  angle  of 
deviation. 


FIG.  40.— The  course  of  a  ray  (A  B  C  D)  refracted  by  a  prism. 

In  Fig.  40  the  ray  A  B  passing  through  the  prism  is 
turned,  so  that  instead  of  continuing  in  the  direction  of 
-Fit  proceeds  toward  7).  The  angle  D E F is  the  angle 
of  deviation.  For  "  crown  "  glass  this  is  somewhat  more 
than  half  the  refracting  angle  B  R  C,  so  that  if  the  prism 
were  numbered  by  degrees  of  deviation,  a  given  number 
would  indicate  a  prism  of  almost  double  strength  of  the 
old  system.  It  is,  however,  proposed  instead  of  number- 
ing the  prism  by  degrees  of  deviation  it  produces,  to 
number  it  by  the  wntrach  (Dennett)  or  prism  diopters 
(Prentice)  of  deviation  that  it  produces.  A  centrad 
Ix-ing  :i  deviation,  the  arc  of  which  is  y^TT  of  the  radius, 
n:id  the  prism  diopter  a  deviation,  the  tangent  of  which 
'~1  yir^  °f  the  radius. 

For  the  strength  of  prisms  ordinarily  used,  these  will 


112 


NUMBERING   OF  PRISMS. 


be  practically  the  same  thing ;  and  numbered  by  either 
centrads  or  prism  diopters,  the  numbering  corresponds 
very  closely  to  that  of  the  old  system,  because  the  prism 
with  one  degree  of  refracting  angle  causes  very  nearly 
one  centrad,  or  one  prism  diopter  of  deviation. 

The  exact  relations  of  the  two  systems  are  shown  in 
the  following  table : 

TABLE  I. — Numbering  of  Prisms. 


DEVIATIONS. 

DEVIATIONS. 

Centrads.     Prism  Diopters.    Angle. 

Centrads.     Prism  Diopters.    Angle. 

1 

1. 

1.06 

9 

9.02 

9.39 

2 

2. 

2.12 

10 

10.03 

10.39 

3 

3. 

3.18 

11 

11.03 

11.37 

4 

4. 

4.23 

12 

12.04 

12.34 

5 

5. 

5.28 

13 

13.06 

13.29 

6 

6.01 

6.32 

15 

15.11 

15.16 

7 

7.01 

7.35 

20 

20.26 

19.45 

8 

8.02 

8.38 

50 

54.62 

36.03 

The  30  centrad  prism  is  just  thirty  times  as  strong  as 
the  1  centrad  prism.  It  will  be  noticed  that  no  such 
relation  exists  between  the  strength  and  the  numbers  of 
the  prisms  by  the  old  system. 

The  practical  uses  of  ophthalmic  prisms  will  be  dis- 
cussed in  connection  with  spectacles  (Chapter  VII)  and 
anomalies  of  the  ocular  muscles  (Chapter  VIII). 

LENSES. 

A  lens  is  a  portion  of  a  dioptric  medium  bounded  by 
one  or  more  curved  surfaces.  In  passing  through  plane 
surfaces,  plane  light-waves  retain  their  original  form,  and 
the  rays  keep  their  original  relation  to  one  another.  In 
passing  through  curved  surfaces,  however,  the  light-waves 
become  curved,  or  their  curves  become  altered,  so  that 
the  relation  of  the  rays  perpendicular  to  them  is  also 
altered. 

This  is  illustrated  in  Fig.  41.  The  portion  of  each 
light-wave  that  strikes  the  lens  first  is  retarded,  the  por- 


LENSES.  113 

tions  remaining  in  the  air  get  ahead  of  it,  changing  the 
shape  of  the  wave-front.  Again,  the  part  of  the  wave- 
front  getting  out  first  gets  ahead  of  the  part  still  in  the 
glass,  and  the  form  of  the  wave  is  still  farther  changed. 


FIG.  41.— Effect  of  convex  lens  on  waves  of  light  passing  through  it. 

In  a  lens,  like  the  one  represented  in  Fig.  41,  thickest  at 
the  center,  called  a  convex  lens,  the  effect  is  to  turn  all 
parts  of  the  wave  toward  the  center,  and  so  to  converge 
it  to  a  single  point  or  focus. 

With  the  opposite  kind  of  lens,  represented  in  Fig. 
42,  called   a   concave   lens,  thinnest  at   the   center  and 


FIG.  42.— Effect  of  concave  lens  on  waves  of  light  passing  through  it. 

thickest  at  the  margins,  the  waves  are  most  retarded  at  the 
margins,  present  convex  surfaces  after  passing  through 
the  lens,  and  tend  to  spread  out  as  though  they  had 


114  FOCUSSING  BY  LENSES. 

started  from  a  certain  point,  or  focus  in  front  of  the 
lens. 

It  is  obvious  that,  in  the  first  case,  all  the  rays  of  light 
tend,  after  passing  through  the  lens,  to  come  together  at 
the  focus,  which  is  called  a  real  focus.  In  the  second 
case,  after  passing  through  the  lens  they  all  diverge  as 
though  they  had  started  from  the  focus,  which  is  called 
a  virtual  focus. 

Another  way  to  understand  a  lens  is  to  regard  it  as 
made  up  of  a  double  series  of  prisms,  very  weak  at  the 
center  of  the  lens  and  increasing  in  strength  as  we  go 
toward  the  margin  (see  Fig.  43).  Near  the  center  the 
rays  will  be  refracted  as  by  a  weak  prism,  and  the  rays 
more  removed  from  the  center  will  be  refracted  as  by 
stronger  and  stronger  prisms. 


FIG.  43.— Refraction  by  a  lens,  resembling  refraction  by  a  series  of  prisms 
which  grow  stronger  the  farther  removed  from  the  optical  center. 

At  one  point  of  every  complete  lens  the  two  surfaces 
arc  parallel.  Rays  passing  through  this  point,  as  through 
a  plate  of  glass  with  parallel  sides,  continue  their  course 
unrefracted.  This  point  is  called  the  optical  center  of  the 
lens.  In  a  convex  lens  it  is  the  thickest  part  of  the  lens ; 
in  a  concave  lens  it  is  the  thinnest  part. 

Varieties  of  I/enses. — Convex  and  concave  lenses 
are  made  of  the  different  forms  represented  in  Fig.  44. 
1  is  called  a  plano-convex,  one  side  being  plane.  2  is  a 
double  convex,  both  sides  being  convex.  It  is  called  bi- 
convex when  both  sides  are  equally  convex.  3  is  a  con- 
cavo-convex, one  side  concave,  the  other  more  convex.  4  is 


LENSES. 


115 


plano-concave,  5  is  a  double  concave  or  bi-concave,  6  is 
convexo-concave ;  3  and  6  are  also  called  meniscus  or  peri- 
scopic  lenses.  All  that  are  thickest  at  the  center  have  the 


23  456 

FIG.  44.— Different  forms  of  convex  and  concave  lenses. 


effect  of  convex  lenses,  and  all  that  are  thinnest  at  the 
center  have  the  effect  of  concave  lenses. 

Strength  of  I/enses. — A  lens  of  a  certain  strength 
causes  a  certain  amount  of  change  in  the  direction  of  rays 
passing  through  it.  If  these  rays  are  parallel  when  they 
fall  upon  it,  they  are  converged  to  a  certain  focus  F  by  a 
convex  lens  (Fig.  45),  or  diverged  from  a  certain  focus 
by  a  concave  lens  (Fig.  46). 

If  rays  diverge  from  the  focus  (Fig.  45)  of  a  convex 
lens,  they  will  be  rendered  parallel  by  it.  If  rays  were 
converging  (Fig.  46)  toward  the  focus  of  a  concave 


FIG.  45.— Focussing  of  parallel  rays 
by  a  convex  lens. 


Fio.4fi.— Concave  lens  dispersing  rays 
as  though  from  its  virtual  focus. 


lens  they  would  be  rendered  parallel  by  it.  The  change 
in  the  direction  of  the  rays  is  the  same  whichever  way 
they  pass  through  the  lens. 

If  instead  of  falling  upon  the  lens  parallel,  they  reach 


116  STRENGTH  OF  LENSES. 

it  somewhat  divergent,  the  convex  lens  will  converge 
them  to  a  focus  farther  away  from  it  than  its  focus  for 
parallel  rays,  or  the  concave  lens  diverge  them  from  a 
focus  nearer  the  lens  than  the  focus  for  the  parallel  rays. 
If  they  fall  on  the  lens  convergent,  the  convex  lens  will 
converge  them  to  a  nearer  focus,  and  the  concave  lens 
will  diverge  them  from  a  focus  farther  away.  Thus,  for 
every  point  from  or  toward  which  the  rays  pass  before 
striking  the  lens  there  will  be  a  corresponding  focus  to  or 
from  which  they  will  go  after  leaving  it.  In  this  way 
every  lens  has  an  infinite  number  of  foci,  corresponding 
to  the  different  distances  from  which  rays  may  come. 

In  order  to  compare  the  strengths  of  different  lenses  it 
is  necessary  to  take  their  focal  distance  for  rays  of  the 
same  sort.  For  this  purpose  the  focal  distance  of  the 
lens  for  parallel  rays  is  taken,  the  focus  for  these  rays 
being  called  the  principal  focus  and  its  distance  from  the 
lens  the  principal  focal  distance. 

If  not  otherwise  indicated,  when  the  focus  of  a  lens  is 
spoken  of,  it  will  be  understood  that  the  principal  focus 
is  referred  to,  and  that  its  focal  distance  means  principal 
focal  distance. 

By  the  strength  of  a  lens  is  meant  its  power  of  turning 
rays  from  their  original  course.  If  this  be  great,  the  lens 
is  spoken  of  as  strong ;  if  it  be  slight,  the  lens  is  weak. 
A  strong  lens  will  bring  rays  quickly  to  a  focus ;  a 
weaker  lens  has  its  focus  at  a  greater  distance.  The  dis- 
tance of  the  focus  from  the  lens  is  the  inverse  or  recip- 
rocal of  the  strength  of  the  lens.  Representing  the  dis- 
tance of  the  focus  from  the  lens  by  F  and  the  strength  of 
the  lens  by  S, 

F-landS=l 

Numbering  of  I/enses. — The  Inch  System. — The 
first  lenses  used  for  ophthalmic  purposes  were  numbered 
according  to  the  radius  of  curvature  of  the  tool  on  which 
they  were  ground,  both  surfaces  having  the  same  curva- 
ture. With  the  glass  commonly  employed  in  them  it 
happened  that  for  such  a  lens,  the  number  indicating  the 


LENSES.  117 

radius  of  curvature  in  inches  also  indicated  approximately 
the  number  of  inches  of  the  principal  focal  distance. 
The  radius  of  curvature  was  a  little  greater  than  the  focal 
distance.  But  most  of  the  early  trial-sets  were  made  in 
Paris  and  Berlin,  and  numbered  according  to  Paris  and 
Berlin  inches,  which  are  slightly  longer  than  the  English 
inch.  Therefore,  in  English-speaking  countries,  the  num- 
ber of  longer  French  or  Prussian  inches  in  the  longer 
radius  of  curvature  almost  exactly  corresponded  to  the 
number  of  shorter  English  inches  in  the  shorter  focal  dis- 
tance. The  numbers,  therefore,  were  soon  generally  re- 
garded as  indicating  the  focal  distance  of  the  lens. 

In  such  a  system  of  numbering  the  strength  of  the  lens 
was  necessarily  expressed  by  a  fraction — one  divided  by 
the  focal  distance  of  the  lens.  Thus,  the  18-inch  lens 
had  a  strength  of  T*g.  In  combining  lenses  in  practical 
work,  it  becomes  necessary  to  add  and  subtract  the 
strengths  of  the  lenses  combined.  Such  calculations 
must  be  made  repeatedly  for  every  eye  that  is  tested,  and 
the  difficulty  of  adding  and  subtracting  vulgar  fractions 
made  it  a  matter  of  serious  importance.  Minor  objec- 
tions to  the  old  system  of  numbering  were  the  variations 
of  inches  in  different  countries,  and  the  irregular  intervals 
in  the  series. 

To  avoid  these  objections  the  dioptric  or  metric 
system  of  numbering  lenses  was  adopted.  In  it  each 
lens  is  numbered  by  its  strength,  in  whole  numbers  or  in 
decimal  fractions,  which  can  be  added  or  subtracted  like 
whole  numbers.  The  unit  is  a  diopter — the  focussing  power 
required  to  bring  parallel  rays  to  a  focus  at  a  distance  of 
1  meter.  A  lens  that  has  this  focussing  power  is  called  a 
1  diopter  lens.  A  lens  having  twice  this  strength  is 
called  the  2.  D.  lens,  and  has  a  focal  distance  of  one-half 
meter.  One  three  times  as  strong  is  a  3.  D.  lens,  and 
has  a  focal  distance  of  one-third  meter.  One  having  only 
a  quarter  of  the  unit  of  strength  is  a  0.25  D.  lens,  and 
has  a  focal  distance  of  4  meters ;  and  so  on  throughout 
the  series. 

The  greater  convenience  and  uniformity  of  the  dioptric 


118  DIOPTRIC  NUMBERING   OF  LENSES. 

or  metric  system  have  caused  its  general  adoption.  It  is, 
however,  well  to  be  familiar  with  the  old  or  inch  system 
of  numbering,  since  in  certain  cases  we  have  to  add  to,  or 
subtract  from,  the  focal  distance  of  a  lens.  In  these 
cases  the  old  or  inch  system  is  much  the  more  convenient, 
because  in  it  the  focal  distances  are  expressed  in  whole 
numbers. 

The  equivalents  for  the  metric  lenses  in  ordinary  use 
are  given  in  the  following  table.  The  first  column  gives 
the  metric  number,  the  second  gives  the  exact  equivalent 
focal  distance  in  inches,  and  the  third  column  gives  the 
nearest  equivalent  commonly  furnished  in  trial  sets,  or 
spectacle  lenses  numbered  according  to  the  old  system. 

TABLE  II. — Numbering  of  Lenses. 

Strength,  Focal  Distance,  Number  in 

Diopters.  Inches.  Old  Series. 

0.12  (0.125)  315. 

0.25  157.5  144 

0.37  105.  100 

0.50  78.7  72 

0.62  63.  60 

0.75  52.5  48 

0.87  45. 

1.  39.37079  40 
1.12  35.  36 
1.25  31.5  30 
1.37  28.6 

1.50  26.2  24 

1.75  22.5 

2.  19.7  20 
2.25  17.5  18 
2.50  15.7  16 
2.75  14.3  14 

3.  13.1 

3.25  12.1  12 

3.50  11.2  11 

3.75  10.5 

4.  9.8  10 
4.50  8.7                9 

5.  7.9                8 
5.50  7.2                7 

6.  6.5  6 

7.  5.6  5} 

8.  4.9  5 

9.  4.4  4J- 


LENSES.  119 

Strength,  Focal  Distance,  Number  in 

Diopters.  Inches.  Old  Series. 

10.  3.9  4 

11.  3.6  31 

12.  3.3 

13.  3.  3 

14.  2.8  2| 

15.  2.6  2£ 

16.  2.4 

17.  2.3  2J 

18.  2.2 

19.  2.1 

20.  2.  2 

The  Trial  Set. — The  lenses  mentioned  in  the  above 
table  are  the  spherical  lenses,  convex  and  concave,  which 
would  be  furnished  in  pairs  in  a  complete  trial  set.  In 
addition  the  set  should  contain  cylindrical  lenses  having 
the  same  numbers  up  to  6.  or  8.  D.,  prisms  of  1  to  20 
centrads,  a  stenopaic  slit,  a  pinhole  disk,  metal  and  ground 
glass  disks,  and  two  or  more  trial  frames  to  support  the 
glasses  before  the  eyes.  Some  of  the  weaker  lenses  may 
be  omitted,  making  the  smallest  interval  0.25  D.  instead 
of  0.12  D.,  without  much  impairing  the  practical  useful- 
ness of  the  set,  even  a  very  much  smaller  set  will  answer 
the  purpose.  Thus  by  combining  two  or  more  lenses, 
one  can  get  all  necessary  powers  from  these  few — 0.25, 
0.50,  0.75,  1.,  2.,  3.,  4.,  5.,  10.,  and  15.  D.  A  larger 
assortment  is  simply  more  convenient. 

Use  of  Trial  Lenses. — The  lenses  are  used  by  placing 
them  before  the  patient's  eye,  to  find  by  trial  the  lens  or 
combination  of  lenses  with  which  he  sees  best.  This 
might  be  thought  to  require  no  special  skill,  and  yet 
accurate  results  with  the  trial  lenses  are  not  obtained 
without  care,  system,  experience,  and  good  judgment. 

If  the  testing  is  too  long  continued,  the  patient's  atten- 
tion is  exhausted,  and  his  answers  become  inaccurate  and 
unreliable.  On  this  account  it  is  always  best  to  know 
pretty  nearly  what  his  refraction  is  before  starting  with 
the  test  lenses.  Here  is  the  great  value  of  other  methods 
of  measuring  refraction.  Then  if  the  patient  does  tire 
with  the  lenses,  he  should  be  allowed  to  go,  and  come 


120  USE  OF  TRIAL   LENSES. 

again  to  have  the  test  completed  at  another  hour  or  on 
another  day. 

To  secure  reliable  answers  the  change  made  in  the  lens 
should  always  be  so  great  that  the  patient  can  certainly 
notice  an  effect  from  it.  Only  when  the  vision  is  normal, 
and  the  patient  is  a  pretty  good  observer,  can  a  0.25  D. 
of  change  be  certainly  recognized.  Until  vision  has  been 
brought  up  to  about  the  normal,  the  changes  in  the  lenses 
should  be  0.50  D.,  or  greater  if  the  vision  is  very  poor. 

The  change  from  one  lens  to  another  should  be  as 
nearly  instantaneous  as  possible.  This  is  accomplished 
by  holding  in  the  hand  both  the  lenses  that  are  to  be  com- 
pared, and  moving  first  one  before  the  eye  and  then  the 
other  in  immediate  succession ;  or  by  placing  one  lens 
in  the  trial-  frame  and  then  holding  before  it  a  weak  sup- 
plementary lens  which,  when  added  to  the  lens  in  the 
trial  frame,  will  make  the  desired  change  of  strength. 
The  supplementary  lens  is  held  before  the  eye  and  then 
removed,  and  this  may  be  repeated  several  times,  so  that  by 
repeated  trials  the  patient  can  make  sure  which  is  the  better. 

Often  it  is  best  to  take  two  supplementary  lenses  in 
the  hand,  one  a  weak  convex,  the  other  a  weak  concave, 
and  by  trying  first  one  and  then  the  other,  to  ascertain  if 
it  makes  the  vision  better,  to  increase  or  to  diminish  the 
strength  of  the  lens  before  the  eye.  Thus,  in  a  case  in 
which  a  4-  2.  D.  lens  seemed  to  be  required,  this  should 
be  placed  in  the  trial  frame  and  a  +  0.50  D.  and  a  — 
0.50  D.  taken  as  supplementary  lenses ;  and  held  alter- 
nately before  the  lens  in  the  trial  frame.  The  patient, 
being  asked  which  makes  vision  better,  may  say  that  the 
—  0.50  D.  makes  it  worse,  but  that  he  is  uncertain  if  the 
+  0.50  D.  really  improves  it.  This  would  indicate  that 
+ 1.50  was  worse  than  +  2.,  but  that  it  was  doubtful  if 
+  2.50  were  better  than  +  2.  Hence,  +  2.25  would  prob- 
ably prove  the  best  correction.  Here  the  doubling  of  a 
change  by  reversal  is  utilized.  When  the  change  from  2. 
to  2.50  did  not  make  a  very  positive  improvement,  the 
comparison  of  the  2.50  with  1.50  gave  unmistakable 
evidence  in  favor  of  the  former. 


REFRACTION  OF  LIGHT. 


121 


The  manner  of  using  cylindrical  lenses  will  be  described 
in  Chapter  VII. 

BIBLIOGRAPHY. 

General  Optical  Principles:  Katoptrics,  Dioptrics,  Physiological 
Optics.  W.  S.  Dennett  and  C.  W.  Cutler,  "  American  Text- 
book." 

The  Dioptrics  of  the  Eye.  Edward  Jackson,  "  System  of  Diseases 
of  the  Eye,"  vol.  i. 

The  Clinical  Use  of  Prisms  and  the  Decentering  of  Lenses.  E.  E. 
Maddox,  180  pp.,  John  Wright  &  Co.,  Bristol. 

The  Metric  System  of  Numbering  Prisms.  S.  Al.  Burnett,  "Oph- 
thalmic Review,"  Jan.,  1891. 

The  Numbering  of  Prisms.  B.  A.  Randall  and  S.  M.  Burnett, 
"Trans.  Sec.  on  Ophthal.  Amer.  Med.  Assoc.,"  1891. 


CHAPTER    VI. 


REFRACTION   OF    THE    EYE;    MYDRIATICS    AND 
MYOTICS;    THE    REFRACTION    OPHTHAL- 
MOSCOPE;   SKIASCOPY. 

Assorting  of  I/ight. — If  we  take  a  convex  lens,  as 
in  Fig.  47,  and  suppose  light  to  fall  upon  it  from  different 
points,  as  A  and  B,  from  each  of  these  points,  one  ray 
will  pass  through  the  optical  center,  entering  the  lens  and 
emerging  from  it  at  points  where  its  two  surfaces  are 


FIG.  47.— Rays  that  pass  through  a  lens  without  being  refracted. 

parallel.     These  rays  will  not  be  refracted,  but  pass  on  in 
their  original  direction.     All  the  other  rays  that  fall  upon 


122  ASSORTING  OF  LIGHT. 

the  lens  will  be  bent  from  their  original  course  toward 
the  rays  passing  through  the  optical  center.  All  the  rays 
from  A  being  bent  toward  a,  and  all  the  rays  from  B 
being  bent  toward  some  point  6.  The  same  thing  is  true 
of  any  number  of  points,  the  rays  from  C  being  collected  at 
c,  and  those  from  D  at  d.  In  this  way  all  the  light  falling 
on  the  lens  is  assorted,  the  light  from  each  point  in  front 
of  the  lens  being  collected  at  a  single  point  behind  it. 

In  the  eye  the  convex  surface  of  the  cornea  acts  on  the 
light  which  enters  it  as  a  convex  lens.  Behind  it  is  the 
crystalline  lens,  acting  as  another  convex  lens.  The 
average  normal  cornea  converges  to  a  point  31  mm.  behind 
it,  having  a  focussing  power  of  32  D.  The  crystalline 
lens  may  be  regarded  as  6  mm.  behind  the  cornea,  where 
the  rays  are  converging  toward  a  point  25  mm.  away— 
that  is,  they  are  convergent  to  40  D.  The  lens  has  a 
converging  affect  of  20  D.,  which,  added  to  the  40  D., 
makes  60  D. ;  and  after  passing  through  the  lens  the  rays 
converge  to  a  point  1000  •*•  60  =  16.667  mm.  behind  it,  or 
22.667  mm.  behind  the  cornea,  the  point  to  which  they 
would  converge  if  the  cornea  had  a  refracting  power  of 
44  D.  This  is  the  dioptric  eye. 

The  eye  may  be  regarded  as  though  the  cornea  and  the 
crystalline  lens  were  replaced  by  a  single  stronger  convex 
lens  situated  at  the  cornea.  Most  of  the  optical  problems 
of  the  eye  can  be  worked  out  more  readily,  and  for  all 
practical  purposes  with  equal  exactness,  with  some  such 
reduced  eye.  The  reduced  eye  of  Donders  has  a  cornea 
with  a  radius  of  5  mm.,  and  the  retina  20  mm.  behind  it. 

In  the  eye  the  assorting  of  the  rays  is  accomplished  by 
its  focussing  power.  This  is  represented  in  Fig.  48.  The 
rays  coming  in  a  certain  direction,  as  from  the  point  A, 
are  focusses  on  a  certain  point  a  within  the  eye.  The 
rays  entering  the  eye  from  the  point  B  are  focussed  at 
the  point  b.  It  will  be  noted  that  the  rays  are  gradu- 
ally concentrated,  until  a  certain  distance  back  from  the 
cornea,  those  coming  from  a  single  point  outside  of  the 
eye  are  brought  to  a  single  point  within  it.  The  assort- 
ing of  the  rays  is  perfect  only  at  this  point.  If  the  rays  pass 


REFRACTION  OF  THE  EYE. 


123 


beyond  ab  they  again  spread  out  and  intermingle.  It  is 
only  at  the  one  distance  that  the  focussing  is  perfect,  and 
at  this  distance  back  of  the  cornea  the  retina  must  be 


FIG.  48.— The  focussing  or  Assorting  of  light  by  the  eye. 

placed,  if  it  is  to  receive  perfectly  focussed  light,  which 
alone  permits  clear  vision. 

Refraction  of  the  Bye. — We  have  seen,  however, 
that  with  any  convex  lens,  the  rays  coming  from  points 
at  different  distances  in  front  of  the  lens  will  be  focussed 
at  different  distances  behind  it.  It  is,  therefore,  custom- 
ary to  speak  of  the  refraction  of  the  eye,  as  we  do  of  the 
refraction  of  a  lens,  with  regard  to  its  influence  on 
parallel  rays. 

An  eye  that  is  so  proportioned  that  parallel  rays  will 
be  focussed  on  the  retina  as  at  E  (that  has  the  principal 
focus  of  its  dioptric  media  on  its  retina)  is  said  to  be 
emmetropic.  Its  state  of  refraction  is  emmdropia.  If 
the  retina  be  situated  in  front  of  the  principal  focus  of 


u  E  M 

FIG.  49.— Position  of  retina  in  hyperopia,  emmetropia,  and  myopia. 

the  dioptric  media,  as  at  IT  (parallel  rays  tending  toward 
a  focus  back  of  the  retina),  its  refraction  is  hyperopia, 
and  the  eye  is  hyperopic  or  hypermetrbpic.  If  the  retina 
is  situated  back  of  the  focus  of  the  dioptric  media,  as  at 
M  (parallel  rays  being  focussed  in  front  of  it),  the  refrac- 


124  REFRACTION  OF  THE  EYE. 

.tion  of  the  eye  is  myopia,  and  the  eye  is  myopic. 
Eraraetropia  must  be  regarded  as  the  standard  of  refraction 
for  the  eye.  All  departures  from  this  standard  are  in- 
cluded under  the  general  term  ametropia.  Such  departures 
from  the  standard  of  ocular  refraction  are  spoken  of  as 
errors  or  anomalies  of  refraction. 

Accommodation. — To  get  distinct  focussing  of  rays 
having  different  degrees  of  divergence  the  eye  has  the 
power  of  varying  its  lens- strength — the  power  of  accom- 
modation. 

The  refraction  of  the  eye*  means  its  optical  condition 
with  reference  to  parallel  rays  when  it  is  entirely  at  rest. 
This  optical  condition  is  independent  of  any  muscular 
exertion,  and  remains  the  same  immediately  after  death, 
or  when  all  power  of  accommodation  is  removed,  as  by 
the  use  of  a  mydriatic.  In  this  condition  its  refraction  is 
at  its  weakest.  The  power  of  accommodation  is  the 
power  to  increase  the  refractive  effect  of  the  eye,  by 
increasing  the  curvature  of  the  crystalline  lens.  This 
increase  of  curvature  is  brought  about  by  the  natural 
elasticity  of  the  crystalline  lens,  which  causes  it  to  assume 
a  more  convex  form,  when  it  is  released  from  the  tension 
of  the  anterior  and  posterior  layers  of  its  capsule,  between 
which  it  is  usually  somewhat  compressed  and  flattened. 
It  is  freed  from  this  compression  by  the  contraction  of 
the  ciliary  muscle.  Helmholtz  believed  the  lens  became 
more  nearly  spherical  during  accommodation,  as  illus- 
trated in  Fig.  50,  A,  which  shows  in  solid  lines  the  outline 
of  the  lens  when  the  accommodation  is  at  rest  and  the 
outline  during  accommodation  in  broken  linen.  Recently 
Tscherning  has  proved  that  during  accommodation  the 
lens  is  more  convex  at  the  center  but  relatively  flattened 
toward  the  periphery.  He  compares  it  to  a  flexible  cane 
bent  over  the  knee,  and  thinks  such  a  change,  indicated 
in  Fig.  50,  7?,  must  be  due  to  increased  tension  of  the  cap- 
sule during  accommodation.  But  llcss  has  shown  that 
the  zonule  is  relaxed  during  accommodation,  and  Priestly 
Smith  has  explained  how  relaxation  of  the  zonule  can 
produce  the  very  change  noted  by  T  .scheming. 


REFRACTION  OF  THE  EYE. 


125 


In  any  case  it  is  certain  that  accommodation  depends 
on  two  factors — the  active  contraction  of  the  ciliary 
muscle,  and  the  flexibility  and  elasticity  of  the  lens. 
In  early  childhood  the  lens  is  most  flexible  and  elastic. 


FIG.  50. — The  changes  in  the  lens  during  accommodation  :  A,  according  to  the 
theory  of  Helmholtz ;  and  B,  according  to  the  theory  of  Tscherning. 

Year  by  year  it  becomes  less  flexible,  and  loses  its  elas- 
ticity ;  until,  at  about  sixty  or  seventy  years  of  age,  it 
becomes  so  rigid  that  it  can  undergo  no  change  of  shape 
under  the  influence  of  the  ciliary  muscle.  The  loss  of 
elasticity  causes  loss  of  power  of  accommodation,  which 
goes  on  until  at  the  age  mentioned  that  power  is  usually 


FIG.  51.— Effect  of  accommodation  in  focussing  rays  from  a  near  point. 


completely   lost.      Later   the   ciliary  muscle   undergoes 
atrophy. 

The  act  of  accommodation  may  be  better  understood 
by  study  of  Fig.  51,  representing  an  emmetropic  eye. 
The  parallel  rays  coming  from  distant  objects  are  focussed 
on  the  retina ;  but  rays  coming  from  a  near  point  P 
would,  with  the  eye  at  rest,  focus  back  of  the  retina  at  p. 
By  increasing  the  convexity  of  the  lens  to  just  the  proper 


126  A  CCOMMODA  TION. 

extent,  the  focus  of  the  dioptric  system  of  the  eye  is 
shortened,  so  that  for  these  diverging  rays  it  falls  upon 
the  retina  at  r. 

The  extent  of  change  in  the  shape  of  the  lens  varies 
with  the  contraction  of  the  ciliary  muscle,  and  can  by  it 
be  adjusted  to  rays  of  various  degrees  of  divergence.  The 
variation  of  refractive  power  of  which  a  given  eye  is  cap- 
able begins  on  the  one  side  at  the  refraction  of  the  eye 
when  entirely  at  rest,  and  extends  on  the  other  side  to 
that  produced  by  the  maximum  contraction  of  which  the 
ciliary  muscle  in  that  particular  eye  is  capable.  When 
this  maximum  power  is  exerted,  rays  of  a  certain  degree 
of  divergence  can  be  focussed  on  the  retina.  The  point 
from  which  come  the  rays  that  can  just  be  focussed  is 
called  the  near  point  (punctum  proximum)  of  distinct 
vision. 

The  difference  in  refractive  power  between  the  dioptric 
system  of  the  eye  with  the  ciliary  muscle  entirely  at  rest 
and  that  of  the  eye  with  the  ciliary  muscle  most  strongly 
contracted  is  called  the  amplitude  of  accommodation.  It 
is  equal  to  the  effect  of  a  convex  lens  of  a  certain  strength, 
and  is  usually  expressed  as  we  express  lens-strength,  in 
diopters.  Thus,  in  an  eye  which  when  at  rest  focusses 
parallel  rays  upon  the  retina,  and  which  has  a  near  point 
of  \  of  a  meter,  from  which  the  rays  reach  the  eye  so 
divergent  that  it  would  take  an  8.  D.  lens  to  make  them 
parallel,  the  power  of  accommodation  is  said  to  be  8.  D. 

The  following  table  gives  the  average  power  of  accom- 
modation in  diopters,  at  different  ages,  with  the  distance 
of  the  near  point  in  inches,  from  an  emmetropic  eye  hav- 
ing such  power  of  accommodation. 

TABLE     III. — Accommodation. 

A.,  Pp.  A.,  Pp. 

Age.  Diopters.  Inches.    Age.  Diopters.  Inches. 

10 14.  2.81  :  40 5.5  7.1 

15 12.  3.28    45 4.  9.84 

20 10.  3.94    50 2.5  15.75 

25 9.  4.4      55 1.25  31.5 

30 8.  4.9      60 0.5  75.74 

35 7.  5.6    165 0  .00 


MYDRIATICS  AND  MYOTICS.  127 


MYDRIATICS  OR  CYCLOPLEQICS,  AND  MYOTICS. 

Drugs  like  atropin,  which  are  known  as  mydriatics, 
on  account  of  the  dilatation  of  the  pupil  they  produce, 
have  also  the  more  important  action  of  producing  cyclo- 
plegia,  or  paralysis  of  the  ciliary  muscle.  These  drugs 
are  as  follows  :  Atropin  is  commonly  used  for  its  cyclo- 
plegic  effect  in  a  solution  of  1  to  120,  4  grains  to  the  fluid 
ounce.  A  single  drop  of  this  solution  in  the  normal  eye 
will  usually  produce  complete  mydriasis  and  cycloplegia ; 
but  if  it  is  entrusted  to  the  patient  or  a  member  of  his 
family  for  application,  it  should  be  instilled  three  times  a 
day.  The  effect  of  such  an  application  begins  in  fifteen 
minutes,  and  reaches  its  maximum  in  two  or  three  hours, 
continues  for  two  or  three  days  with  very  little  alteration, 
and  gradually  passes  off  in  two  weeks. 

jDofefrio,  hyoscyamin,  duboisin,  and  scopolamin  are  used 
in  solutions  half  or  less  than  half  the  strength  of  that  of 
atropin.  Their  effect  is  similar,  but  begins  in  eight  or 
ten  minutes,  reaches  a  maximum  in  one  or  two  hours,  and 
passes  off  in  a  week  or  ten  days.  Scopolamin  is  some- 
times used  in  one-tenth  of  1  per  cent,  solution,  instilled  two 
or  three  times  ;  and  in  this  way  proves  an  efficient  cyclo- 
plegic,  rather  more  brief  in  its  action  than  when  used  in 
stronger  solution. 

Homatrofjin  is  used  in  2  or  3  per  cent,  solution,  10  or 
15  grains  to  the  fluid  ounce,  and  even  in  that  strength 
must  be  used  four  or  five  times  at  intervals  of  five  min- 
utes, to  produce  full  cycloplegia.  It  begins  to  act  in  fif- 
teen minutes,  reaches  its  maximum  influence  in  one  hour, 
and  passes  off  in  about  two  days. 

All  of  these  drugs  are  liable  in  the  doses  mentioned  to 
cause  constitutional  symptoms,  but  homatropin  causes 
them  very  rarely  and  less  severely  than  any  of  the  others. 
On  this  account,  and  because  of  the  brevity  of  its  action, 
it  is  to  be  preferred  to  other  cycloplegics  for  diagnostic 
purposes. 

The  use  of  one  of  these  drugs  is  necessary,  whenever 
it  is  desired  to  make  a  complete  study  and  accurate  meas- 


128  MYDRIATICS. 

urement  of  the  refraction,  in  a  patient  under  fifty  years 
of  age.  Without  them  the  refraction  can  be  guessed  at, 
often  correctly.  Many  patients  have  all  their  hyperopia 
manifest,  even  in  early  life ;  and  in  most  eyes  prolonged 
and  careful  study,  by  all  the  objective  and  subjective 
methods,  will  reveal  approximately  the  astigmatism.  But 
without  a  cycloplegic,  one  cannot  be  certain  of  his  ground, 
he  will  generally  be  less  accurate  in  his  refraction  work, 
and  in  occasional  cases  he  will  make  the  most  serious 
blunders.  Since  patients  usually  come  to  a  doctor  for 
glasses  because  they  want  certainty,  as  opposed  to  the 
guessing  of  the  optician,  and  since  no  serious  inconvenience 
is  entailed,  and  the  strained  eyes  are  benefited  by  the  use 
of  homatropin  or  one  of  the  slower  cycloplegics,  they 
should  generally  be  used  in  studying  the  refraction  of  the 
eye  up  to  the  age  of  fifty.  Let  it  be  remembered  that 
accommodation  fails  first  from  increasing  rigidity  of  the 
lens,  and  not  from  weakness  of  the  ciliary  muscle. 
Hence  about  as  strong  a  cycloplegic  is  required  to  paralyze 
the  accommodation  at  forty  as  in  childhood. 

When  symptoms  of  mydriatic  intoxication  do  arise — 
usually  unsteadiness  of  gait,  or  in  children  a  pleased 
delirium — the  instillation  of  the  drug  should  be  stopped, 
morphin  administered  in  small  doses,  and  water  given 
freely  to  favor  elimination.  Although  a  small  dose  of 
one  of  these  drugs  may  cause  symptoms  that  will  alarm 
those  about  the  patient,  the  dangerous  dose  is  much  larger 
than  the  quantity  commonly  used  as  a  cycloplegic. 

After  the  age  when  accommodation  ceases  to  interfere 
with  the  measurement  of  refraction,  it  is  sometimes  neces- 
sary to  use  a  mydriatic  simply  to  enlarge  the  pupil,  as  the 
extreme  contraction  of  the  pupil  sometimes  found  in 
elderly  people  prevents  the  satisfactory  examination  of 
the  fund  us  or  the  accurate  measurement  of  the  refraction. 
To  overcome  such  contraction  of  the  pupil  a  solution  of 
cocain  2  to  4  per  cent.,  or  the  homatropin  and  cocain 
solution  may  be  used.  These  will  require  from  thirty  to 
fifty  minutes  to  dilate  the  pupil.  They  do  not  prevent  its 
contraction  in  strong  light,  avoiding  much  of  the  dazzling 


MYDRIATICS  OR  CYCLOPLEGICS,  AND  MYOTICS.   129 

caused  by  the  other  mydriatics,  yet  in  a  dark  room  or  in 
a  moderate  light  they  dilate  the  pupil  more  widely  than 
do  the  "  stronger  "  mydriatics,  and  the  effect  passes  off  in 
about  twelve  hours. 

Euphthalmin,  a  true  mydriatic  more  feeble  and  brief  in 
its  action  than  homatropin,  is  a  valuable  dilator  of  the 
pupil  for  diagnostic  purposes,  but  has  no  practical  value 
as  a  cycloplegic.  It  is  used  in  a  2  to  5  per  cent,  solution 
of  the  hydrochlorate,  or  a  solution  of  1  per  cent,  each  of 
euphthalmin  and  cocain  hydrochlorates. 

The  myotics  are  drugs  which  produce  myosis — con- 
traction of  the  pupil — and  also  cause  increased  contraction 
of  the  ciliary  muscle.  In  these  respects  they  are  direct 
antagonists  of  the  mydriatics ;  but  in  other  ways,  as  in 
their  influence  on  the  nutrition  of  the  cornea,  they  have 
an  effect  quite  similar  to  that  of  atropin. 

Eserin,  or  Physostigmin. — A  single  drop  of  a  solution  of 
the  sulphate  1  to  2000,  \  grain  to  the  fluid  ounce,  in  the 
normal  eye  will  produce  a  marked  contraction  of  the 
pupil,  and  increase  the  power  of  accommodation,  and  in 
sensitive  eyes  causes  painful  spasm  of  the  sphincter  of  the 
pupil  and  of  the  ciliary  muscle,  with  dimness  of  vision. 
Shortly  after  its  instillation  there  is  generally  a  twitching 
of  the  lids,  which  lasts  ten  or  fifteen  minutes.  In  fifteen 
minutes  the  effect  on  the  pupil  is  noticeable.  The  effect 
reaches  the  maximum  in  one  or  two  hours,  and  passes  off 
entirely  in  thirty-six  to  forty-eight  hours.  In  old  people, 
in  whom  the  ciliary  muscle  is  atrophied  and  the  pupil 
sluggish,  eserin  is  less  likely  to  produce  a  painful  spasm, 
and  can  be  used  more  freely. 

Piloearpin  is  commonly  employed  as  a  hydrochl orate. 
It  is  twenty  to  twenty-five  times  weaker  than  eserin,  and 
not  liable  to  cause  painful  spasm  in  the  iris  or  ciliary 
muscle.  A  drop  of  a  solution  1  to  500  (gr.  to  f  %  j)  pro- 
duces contraction  of  the  pupil  and  increase  of  accommo- 
dation, beginning  in  twenty  to  thirty  minutes,  reaching  a 
maximum  in  one  or  two  hours,  and  passing  off  in  eight  to 
twelve  hours. 


130  MYOTICS. 

For  details  regarding  the  practical  use  of  mydriatics 
and  myotics  see  Chapter  XVIII. 

OPTICAL  THEORY  OF  THE  OPHTHALMOSCOPE. 

Since  the  eye  is  able  to  focus  the  rays  from  a  point  out- 
side of  it  to  a  single  point  on  its  retina,  and  since  the 
dioptric  media  exert  the  same  influence  on  the  light 
emerging  from  the  eye  as  upon  the  light  entering  it,  the 
rays  from  any  particular  point  of  the  retina  that  pass  out 
through  the  pupil  will  all  be  turned  toward  a  certain 
point  outside  of  the  eye.  Hence,  on  looking  into  an  eye, 
only  those  rays  can  reach  the  observer  which  come  from 
a  certain  part  of  the  retina.  In  Fig.  48  (p.  123),  looking 
into  the  eye  from  A,  only  rays  will  be  received  that  come 
from  a.  But  the  retina  at  a  receives  rays  only  from  the 
direction  of  A.  Hence,  when  an  observer's  eye  is  placed 
at  A  and  shuts  off,  as  it  necessarily  does,  a  considerable 
amount  of  light  from  entering  the  observed  eye  in  this 
direction,  the  part  of  the  retina  at  a  is  in  shadow.  Al- 
though the  retina  at  b  may  be  brightly  illuminated,  all 
the  light  from  b  passes  to  B,  and  so  of  all  points  of  the 
interior  of  the  eye.  The  pupil  of  the  observed  eye,  there- 
fore, appears  black.  In  looking  into  the  eye  under  ordi- 
nary conditions,  although  other  parts  of  the  retina  may 
be  brilliantly  lighted  up,  the  part  of  the  retina  that  the 
observer  sees  is  always  in  shadow. 

To  overcome  this,  and  light  up  the  part  of  the  retina 
looked  at,  the  ophthalmoscope  was  devised.  It  enables 
one  to  examine  the  interior  of  the  eye  by  throwing  light 
from  the  mirror  on  the  part  of  the  retina  looked  at. 

The  mirror  commonly  used  is  concave.  It  converges 
the  light  reflected  from  it,  throwing  a  larger  amount  of 
light  info  the  pupil  than  would  a  plane  mirror.  This 
light,  being  convergent,  is  generally  focussed  in  front  of 
the  retina,  and  forms  on  the  retina  a  circle  of  diffused 
light,  favorable  for  revealing  changes  in  the  tissues  ex- 
amined. In  eyes  that  are  highly  hyperopic  the  rays  may 
be  focussed  on  the  retina,  in  \\hich  case  a  small  com- 


REFRACTION  OPHTHALMOSCOPE.  131 

paratively  distinct  image  of  the  lamp-flame  is  seen, 
instead  of  the  larger  uniformly  illuminated  circle.  The 
mirrors  employed  on  most  American  ophthalmoscopes 
have  a  focussing  distance  of  6  or  8  inches,  a  sort  of  com- 
promise between  that  which  would  be  best  for  the  direct, 
and  that  which  would  be  best  for  the  indirect  method  of 
examination.  For  the  direct  examination  a  mirror  of 
about  4  inches  focal  distance  is  most  satisfactory.  For 
the  indirect  method  one  of  10  to  15  inches  focal  distance 
is  better. 

If  the  ophthalmoscope  is  furnished  with  two  mirrors, 
the  one  for  the  direct  examination  should  be  small — 15 
mm.  in  diameter — and  should  tilt.  For  the  indirect 
method  of  examination,  the  mirror  need  not  tilt  and  may 
be  much  larger,  since  whatever  its  size,  light  can  be  con- 
centrated from  all  parts  of  it  upon  the  pupil.  The  mirror 
in  ordinary  use,  shown  in  Fig.  25,  is  called  the  "  rect- 
angular tilting  mirror."  The  size  of  the  sight-hole  in- 
fluences the  ease  with  which  the  instrument  can  be  used 
to  inspect  the  fundus  of  the  eye,  and  the  accuracy  with 
which  it  will  measure  refraction.  If  the  sight-hole  be 
small,  it  is  comparatively  easy  to  obtain  a  clear  view  of 
the  fundus,  but  the  determination  of  the  refraction  will 
be  comparatively  inexact.  If  the  sight-hole  be  large,  the 
instrument  will  be  more  valuable  to  measure  refraction,  but 
less  perfectly  suited  to  show  the  condition  of  the  fundus 
through  an  undilated  pupil. 

THE    DIRECT    METHOD  FOR    THE  MEASUREMENT  OF 
REFRACTION. 

Emmetropia. — If  the  surgeon's  eye  be  placed  as  close 
as  possible  to  the  pupil  of  the  patient's  eye,  it  will  receive 
rays  as  they  pass  from  the  latter — parallel,  divergent,  or 
convergent.  If  the  surgeon's  eye  be  emmetropic  and  his 
accommodation  relaxed,  parallel  rays  will  be  accurately 
focussed  on  his  retina,  as  illustrated  in  Fig.  52,  and  a 
clear  view  of  the  retina  and  choroid  will  be  obtained. 

Hyperopia. — If  the  patient's  eye  be  hyperopic  and 


132  HYPEROPIA. 

entirely  at  rest,  the  rays  from  his  retina  will  diverge 
on  leaving  the  cornea ;  and,  to  render  them  parallel  will 


FIG.  52. — Course  of  the  rays  in  emmetropia. 

require  such  a  convex  lens  as  would  cause  parallel  rays  to 
be  focussed  on  the  patient's  retina.  If  this  lens  be  placed 
as  represented  by  the  solid  lines  in  Fig.  53,  it  will 


FIG.  53. — Course  of  the  rays  in  hyperopia,  patient's  eye  on  the  left.  Dotted 
lines  show  effect  of  accommodation  in  patient's  eye;  broken  lines  show  effect 
of  accommodation  in  the  surgeon's  eye. 

render  the  divergent  rays  parallel ;  they  will  be  focussed 
on  the  surgeon's  retina,  and  the  details  of  the  fundus  will 
be  clearly  seen. 

If  the  patient  exerts  any  power  of  accommodation,  the 
rays  emerge  from  his  cornea  less  divergent,  parallel,  or 
even  convergent.  In  such  a  case  the  convex  lens,  other- 
wise required,  focusses  the  rays  in  front  of  the  surgeon's 
retina,  and  a  blurred  image  results.  Such  a  course  of 
the  rays  is  illustrated  by  the  dotted  lines  in  Fig.  03. 
Again,  if  the  surgeon  whose  eye  is  emmetropic  exerts  his 
own  accommodation,  he  will  no  longer  accurately  focus 
parallel  rays,  and  will  receive  from  them  only  a  blurred 
image.  Such  a  course  of  the  rays  is  shown  by  the  broken 
lines. 

If  accommodation  is  used  during  such  an  examination, 
a  weaker  convex  lens,  or  none  at  all,  or  even  a  concave 


REFRACTION  OPHTHALMOSCOPE.  133 

lens  will  be  required,  and  this  is  true  whether  the  accom- 
modation be  in  the  patient's  eye  or  in  the  surgeon's. 

In  myopia,  as  shown  in  Fig.  54,  the  rays  from  the 
patient's  retina  emerge  convergent ;  and  without  a  lens 
they  would  be  focussed  in  front  of  the  surgeon's  retina, 


FIG.  54. — Course  of  the  rays  in  myopia.    Dotted  lines  show  A.  in  patient's  eye ; 
broken  lines  show  A.  in  surgeon's  eye. 

giving  only  a  blurred  image.  By  placing  before  the  eye 
a  concave  lens  just  strong  enough  to  correct  the  myopia, 
these  rays  are  rendered  parallel,  and  the  surgeon  is  able 
to  focus  them  on  his  retina.  The  use  of  any  accommoda- 
tion in  this  case,  either  in  the  patient's  or  in  the  surgeon's 
eye,  will  again  bring  the  rays  to  a  focus  in  front  of  the 
retina,  illustrated  as  in  the  case  of  hyperopia  by  dotted 
and  broken  lines,  and  will  render  necessary  the  employ- 
ment of  a  concave  lens  stronger  than  is  required  to  cor- 
rect the  myopia — one  strong  enough  to  correct  the  myopia 
and  neutralize  the  accommodation  too. 

Hence,  the  surgeon's  eye  being  emmetropic,  if  no  ac- 
commodation be  used,  the  lens  that  will  give  the  clearest 
view  of  the  patient's  fundus  is  the  one  that  will  correct 
the  ametropia. 

If  any  accommodation  be  used,  the  strongest  convex 
lens,  or  the  weakest  concave  lens,  giving  a  clear  view  of 
the  fundus,  will  be  the  nearest  right. 

If  the  surgeon's  eye  be  ametropic,  he  must  use  an  addi- 
tional lens  to  correct  his  ametropia,  or  must  add  or  sub- 
tract such  correction  to  find  the  ametropia  in  the  patient's 
eye. 

The  measurement  of  refraction  can  be  made  with  the 
ophthalmoscope,  with  approximate  accuracy,  only  after 
long  practice.  The  chief  obstacle  to  accuracy  is  the  exer- 


134 


MYOPIA. 


tion  of  an  unknown  amount  of  accommodation.  This 
may  be  combated  in  the  surgeon's  eye  by  practice.  Ac- 
commodation in  the  patient's  eye  may  be  overcome  by  the 
use  of  a  cycloplegic.  It  may  often  be  relaxed  by  making 
the  ophthalmoscopic  examination  in  a  large,  thoroughly 
darkened  room,  with  the  patient's  gaze  fixed  on  a  perfectly 
blank  wall  at  the  farther  end.  But  the  measurement  of 
refraction  by  the  ophthalmoscope  can  never  be  relied  on 
for  the  accurate  prescription  of  lenses.  It  is  chiefly  of 
value  for  an  approximate  diagnosis,  or  to  determine  the 
extent  of  swelling  in  the  fundus,  or  the  location  of  an 
opacity  in  the  vitreous. 

The  actual  shortening  or  lengthening  of  the  eye,  cor- 
responding to  different  degrees  of  hyperopia  and  myopia, 
is  shown  by  the  following  table  : 

TABLE  IV. — Changes  in  the  Visual  Axis  for  Each  D. 
of  Ametropia. 


Diopters. 
1  .    .    .    . 

H., 
Shorten- 
ing. 

.    .    .31 

M., 
Lengthen- 
ing. 

.32 

2  .... 

.    .     62 

.66 

3  .... 

.    .    .92 

1.01 

4  .... 

.    .  1.21 

1.87 

5  .... 

.    .  1.50 

1.74 

6  .... 

.    .  1.76 

2.13 

7  .... 

.    .  2.03 

2.52 

8  .... 

.    .  2.28 

2.93 

9  .... 

.    .  2  53 

335 

10. 

2.78 

3.80 

Diopters. 

11  ... 
12  ... 
13  ... 
14.  .. 
15  ... 
16  ... 

H., 
Shorten- 
ing. 

.    .  3.02 
.    .  3.25 
.    .  3.47 
.    .  3.69 
.    .  3.91 
.    .  4.11 

M., 

Lengthen- 
ing. 

4.26 
4.73 
5.23 

5.74 

6.28 
6.83 

17  ... 
18.  .. 
19  ... 
20  .  . 

.    .  4.32 
.    .  4.52 
.    .  4.71 
.    .  4.90 

7.41 
8.03 
8.65 
9.31 

SKIASCOPY. 

Myopia. — As  already  mentioned,  rays  from  the  retina 
of  the  myopic  eye  pass  into  the  air  convergent.  If  not 
interrupted  in  their  course  they  continue  to  converge  until 
they  are  focussed  at  that  point  in  front  of  the  eye,  for 
which  it  is  optically  adjusted.  This  is  true  of  rays  com- 
ing from  each  point  of  the  retina,  so  that  at  that  distance 
there  is  formed  an  image  of  the  fundus.  This  image  is 
inverted,  as  is  illustrated  in  Fig.  55.  The  rays  from  the 


SKIASCOPY.  135 

lower  part  of  the  retina  come  to  a  focus  above,  and  form 
the  upper  part  of  the  image,  and  the  rays  from  the  upper 
part  of  the  retina  are  focussed  below  to  form  the  lower 
part  of  the  image.  If  the  surgeon  places  his  eye  closer 
than  this  image  to  the  eye  of  the  patient,  as  at  A  in  Fig. 


FIG.   55.— Focussing  of  rays  coining  from  the  retina  in  skiascopy ;  and  the 
point  of  reversal. 

55,  he  will  observe  the  fundus  of  the  patient's  eye  in  an 
erect  image,  as  he  does  in  the  direct  method  of  ophthal- 
moscopic  examination.  This  image  may  require  a  con- 
cave lens  to  render  it  clear ;  but  whether  clear  or  dim,  it 
is  necessarily  erect.  If  the  surgeon's  eye  be  placed 
farther  from  the  patient's  than  £,  as  at  C  he  will  no 
longer  view  the  erect  image,  but  will  perceive  the  inverted 
image  formed  in  the  air  at  B.  This  inverted  image  may 
require  the  use  of  a  convex  lens  to  focus  it  clearly  upon 
the  surgeon's  retina ;  but  whether  clearly  focussed  or  not, 
it  is  always  an  inverted  image. 

We  have,  therefore,  at  the  point  B,  for  which  the 
myopic  eye  is  optically  adjusted,  reversal  of  the  image 
seen  ;  this  point  we  therefore  name  the  point  of  reversal. 
Its  position  is  to  be  determined  by  noticing  where  the 
erect  changes  into  the  inverted  image,  or  vice  versa". 
Having  ascertained  its  position,  the  measurement  of  its 
distance  from  the  patient's  eye  gives  the  focal  distance  of 
the  lens  required  to  correct  his  myopia. 

Details  of  the  Test. — Skiascopy  (the  shadow-test 
or  retinoscopy)  is  a  method  of  determining  the  position 
of  this  point  of  reversal,  by  noting  the  apparent  direction 
of  the  movement  of  light  and  shadow  across  the 
pupil.  The  movement  of  light  and  shadow  in  the  pupil 


136 


DETAILS  OF  THE  TEST. 


is  produced  by  changing  the  inclination  of  a  perforated 
mirror  which  reflects  light  into  the  eye. 

The  best  light  is  furnished  by  acetylene  gas,  next  conies 
that  of  the  incandescent  mantle  (Welsbach),  or  a  good 
candle ;  but  a  gas  or  kerosene-flame  will  answer.  The 
mirror  employed  may  be  either  plane  or  concave. 

With  the  plane  mirror  the  source  of  light  is  to  be 
brought  as  close  to  the  mirror  as  possible,  and  shaded 
from  the  patient's  face,  as  shown  in  Fig.  56,  an  opening 


FIG.  56.— Position  of  light  (L),  mirror  (M),  and  eyes  of  surgeon  (0)  and  patient 
(P)  for  skiascopy  with  the  plane  mirror. 

5  mm.  in  diameter  being  left  in  the  shade  opposite  the 
brightest  part  of  the  flame.  The  mirror  should  have  a 
central  opening  2  to  2.5  mm.  in  diameter. 

The  effect  of  changing  the  inclination  of  the  mirror  is 
represented  in  Fig.  57,  in  which  light  from  the  lamp-flame 


FIG.  57.— Skiascopy  with  the  plane  mirror. 

L  is  reflected  into  the  eye  from  the  mirror  first  held  at 
A  A  and  then  moved  to  B  R,  With  the  mirror  at  A  A, 
the  light  enters  the  eye  as  though  it  came  from  I,  and 
falls  on  the  retina  toward  a.  With  the  mirror  nt  />  B, 
the  light  enters  the  eye  as  though  it  came  from  /',  and  it 


SKIASCOPY.  137 

falls  in  the  direction  of  b.  As  the  mirror  is  moved  from 
A  A  to  B  B,  the  light  moves  on  the  retina  from  a  to  6. 
At  the  same  time  the  part  of  the  light  from  the  mirror 
which  falls  on  the  face  about  the  eye,  moves  upward — 
that  is,  the  light  on  the  retina  moves,  "  with  "  the  light 
on  the  face — "  with  "  the  mirror. 

This  happens  whether  the  retina  be  situated  at  H,  E, 
or  M ;  whether  the  eye  be  hyperopic,  emmetropic,  or 
myopic.  With  the  plane  mirror  the  real  movement  of 
the  light  upon  the  retina  is  always  "  with  "  the  movement 
on  the  face.  If  the  retina  be  seen  in  the  erect  image,  the 
apparent  movement  of  the  light  in  the  pupil  will  be 
"  with  "  the  light  on  the  face.  If  the  retina  be  seen  with 
the  inverted  image,  the  apparent  movement  of  the  light 
in  the  pupil  will  be  the  opposite  of  the  real  move- 
ment. Farther  from  the  patient's  eye  than  the  point  of 
reversal,  the  light  in  the  pupil,  therefore,  appears  to  move 
"  against "  the  light  on  the  face. 

With  a  concave  mirror  the  movement  of  the  light  and 
shade  will  be  just  the  opposite  of  the  above.  Why  this 
is  so  is  illustrated  in  Fig.  58.  L,  the  lamp-flame,  is  placed 


JB  A 


PIG.  58. — Skiascopy  with  the  concave  mirror. 

behind  the  patient,  the  rays  from  it  being  focussed  by  the 
concave  mirror  at  /  when  the  mirror  is  at  A  A,  and  at  I' 
when  the  mirror  is  at  B  B.  From  I  they  enter  the  eye 
toward  a  on  the  upper  part  of  the  retina.  From  I'  they 
fall  on  the  lower  part  of  the  retina  toward  6.  When 
the  mirror  is  at  A  A,  the  light  is  thrown  down  on  the 


138  DETAILS  OF  THE  TEST. 

face,  but  falls  on  the  upper  part  of  the  retina.  When  the 
mirror  is  at  B  B  the  area  of  the  light  is  higher  on  the 
face,  but  lower  upon  the  retina.  Hence,  with  the  con- 
cave mirror  the  light  on  the  retina  really  moves  "  against " 
the  mirror — "against"  the  light  on  the  face. 

The  apparent  movement  of  the  light  being  watched  in 
the  pupil,  when  the  erect  image  is  seen  will  be  in  the  real 
direction,  and  when  seen  in  the  inverted  image,  in  the 
opposite  direction.  Hence,  in  any  case  of  myopia,  testing 
with  the  plane  mirror  will  show  the  light  moving  "  with  " 
the  light  on  the  face  when  viewed  closer  than  the  point 
of  reversal,  and  moving  against  the  light  on  the  face 
when  viewed  from  beyond  the  point  of  reversal.  If 
tested  with  a  concave  mirror,  it  will  show  the  light  in  the 
pupil  moving  "against"  the  lighten  the  face  from  within 
the  point  of  reversal,  and  "  with  "  the  light  on  the  face 
beyond  the  point  of  reversal. 

Distance. — In  practice  one  should  vary  his  distance  so 
as  to  try  the  movements  both  from  within  the  point  of 
reversal  and  from  beyond  it,  until  the  approximate  posi- 
tion of  that  point  is  determined  with  certainty.  When 
the  plane  mirror  is  used,  the  distance  of  the  surgeon  from 
the  patient  can  be  varied  greatly,  without  interfering 
much  with  the  accuracy  of  the  test.  With  a  concave 
mirror,  however,  but  very  slight  variations  of  distance 
between  the  patient  and  the  surgeon  are  admissible.  It 
is  necessary  to  keep  the  surgeon's  eye  a  fixed  distance 
from  the  patient's,  and  cause  the  distance  of  the  point  of 
reversal  to  vary,  by  placing  before  the  patient's  eye  lenses 
that  will  correct  more  or  less  of  the  myopia.  The  distance 
for  the  usual  concave  ophthalmoscopic  mirror  should  be 
rather  less  than  1  meter.  The  lens  that  brings  the  point 
of  reversal  to  1  meter  is  one  that  corrects  all  the  myopia 
but  1.  D.,  which  must  be  added  to  the  strength  of  the  lens 
to  get  the  total  myopia. 

When  the  plane  mirror  is  employed  and  the  distance 
varied,  that  distance  must  be  measured,  or,  at  least,  ap- 
proximately estimated,  and  the  myopia  corresponding  to 
it  added  to  that  represented  by  the  correcting  lens  em- 


SKIASCOPY.  139 

ployed.  The  accurate  determination  of  the  point  of 
reversal  requires  it  to  be  brought  about  ^  to  1  meter 
before  the  eye. 

Hyperopia. — In  hyperopia  the  rays  from  the  retina 
emerge  from  the  eye  divergent.  There  can  be  no  inverted 
image,  no  point  of  reversal,  until  a  convex  lens  strong 
enough  to  more  than  correct  it,  is  placed  before  the  eye. 
The  light  in  the  pupil  will  move  "  with"  the  light  on  the 
face  with  a  plane  mirror,  and  "against"  the  light  on  the 
face  with  a  concave  mirror  at  all  distances.  To  measure 
the  hyperopia  the  rays  which  leave  the  patient's  eye 
divergent  must  be  rendered  convergent  by  a  convex  lens, 
as  L  in  Fig.  59.  The  position  B  of  the  point  of  reversal 


FIG.  59.— Rays  emerging  from  a  hyperopic  eye  rendered  convergent  to  give  a 
point  of  reversal. 

for  this  myopic  combination  of  the  eye  and  lens  is  then 
determined,  and  thus  the  amount  of  myopia  that  the  lens 
causes. 

The  lens  L  may  be  regarded  as  doing  two  things.  Part 
of  its  effect  is  to  make  the  divergent  rays  parallel,  cor- 
recting the  hyperopia ;  the  remainder  of  its  strength 
makes  the  parallel  rays  convergent,  causing  an  artificial 
myopia.  The  amount  of  the  lens-strength  causing  con- 
vergence of  the  rays,  deducted  from  the  whole  strength 
of  the  lens  used,  gives  the  strength  required  to  correct  the 
hyperopia.  Tims  with  +  3.  D.  lens,  causing  1.  D.  of 
artificial  myopia,  3.  D.  —  1.  D.  -—  2.  D.,  the  amount  of 
lens-strength  required  to  correct  the  hyperopia  in  the 
eye. 

Ummetropia. — When  the  eye,  tested  as  for  hyperopia, 
shows  an  amount  of  myopia  produced  just  equal  to  the 
strength  of  the  convex  lens  used,  it  is  evident  that  the 


140  KMMETROPIA. 

hyperopia  of  the  eye  was  0 — that  is,  that  the  eye  was 
emrnetropie  to  start  with. 

Appearance  of  the  I/ight  in  the  Pupil. — \Vhcn 
the  surgeon's  eye  is  near  the  point  of  reversal,  it  sees  the 
patient's  retina  enormously  magnified  and  the  movement  of 
the  light  and  shadow  in  the  pupil  appears  correspondingly 
rapid.  When  the  surgeon's  eye  is  far  removed  from  the 
point  of  reversal,  when  there  is  much  uncorrected  myopia 
or  hyperopia,  the  apparent  movement  of  the  light  and 
shadow  in  the  pupil  is  slow.  Just  at  the  point  of  reversal, 
or  at  a  great  distance  from  it,  the  illumination  is  found 
comparatively  feeble,  and  the  boundary  between  light  and 


FIG.  60. — Appearance  of  light  in  the  pupil:  A,  about  1.  D.  from  the  point  of 
reversal,  and  B,  about  5.  D.  from  the  point  of  reversal. 

shadow  indefinite.  At  about  1.  or  2.  D.  from  the  point 
of  reversal,  the  brightest  illumination  and  most  distinct 
movement  of  the  light  and  shadow  in  the  pupil  are  ob- 
served. When  these  points  are  borne  in  mind,  the 
rapidity  in  movement  and,  to  some  extent,  the  brilliancy 
of  illumination  become  approximate  indications  of  the 
amount  of  ametropia  to  be  corrected. 

Of  the  appearance  of  the  pupillary  light-area  in  regular 
astigmatism,  aberration,  and  irregular  astigmatism,  more 
will  be  said  in  connection  with  these  forms  of  ametropia. 

Practical  Applications  of  the  Test. — The  room 
should  be  darkened  and  the  lamp-flame  shaded  by  an 
opaque  chimney,  the  circular  opening  for  the  emission  of 
light  being  turned  toward  the  surgeon's  eye.  For  the 
plane  mirror  the  source  of  light  is  to  be  kept  as  close  to 
the  surgeon's  eye  as  possible  (see  Fig.  56),  and  must  be 


SKIASCOPY.  141 

movable.  With  the  concave  mirror  the  light  should  be 
placed  behind  the  patient,  about  2  meters  from  the  sur- 
geon ;  and  the  opening  in  the  shade  may  be  25  to  30  mm. 
in  diameter,  or  the  shade  can  be  omitted.  This  gives  the 
concave  mirror  an  advantage  when  the  test  must  be 
applied  away  from  office  facilities. 

The  mirror,  being  turned  so  as  to  reflect  the  light  into 
the  patient's  eye,  is  rotated  slightly  from  side  to  side.  If 
with  the  plane  mirror  the  light  moves  "against"  the  light 
on  the  face,  there  is  a  point  of  reversal  between  the  sur- 
geon's eye  and  the  patient's  eye.  Its  position  is  to  be 
determined  by  coming  closer  to  the  patient,  or  by  placing 
a  concave  lens  that  will  bring  this  point  of  reversal  to  the 
distance  of  the  surgeon's  eye. 

If  the  movement  with  the  plane  mirror  is  "  with  "  the 
light  on  the  face,  there  is  no  point  of  reversal  in  front  of 
the  surgeon's  eye,  but  one  must  be  brought  there  with  a 
convex  lens.  If  the  convex  lens  that  brings  the  point  of 
reversal  to  a  certain  position  be  weaker  than  the  amount 
of  myopia  corresponding  to  that  distance,  the  case  is  one 
of  low  myopia.  If  the  amount  of  myopia  exactly  equals 
the  lens-strength,  the  eye  is  emmetropic.  If  the  myopia 
produced  by  the  convex  lens  be  less  than  the  strength  of 
the  lens,  the  eye  is  hyperopic.  The  point  of  reversal  is 
to  be  ascertained  by  repeated  trials  both  from  within  and 
from  beyond  it.  Generally  its  location  will  be  most  ac- 
curately determined  by  fixing  it  at  the  greatest  distance  at 
which  movement  "  with "  the  light  on  the  face  is  seen 
with  the  plane  mirror,  or  the  shortest  distance  at  which  it 
is  noticeable  with  the  concave  mirror. 

To  secure  accuracy,  it  is  well  to  make  the  final  deter- 
mination with  the  point  of  reversal  as  far  from  the  eye  as 
the  movement  of  light  and  shade  can  be  certainly  recog- 
nized. If  the  pupil  has  the  same  refraction  in  all  parts, 
this  distance  may  be  1  meter.  If  the  movement  has  to 
be  watched  in  a  comparatively  small  portion  of  the  pupil, 
the  refraction  and  movement  there  being  different  from 
the  refraction  and  movement  in  other  portions,  it  is  neces- 
sary to  make  the  test  from  a  shorter  distance. 


142          THEORY  OF  THE  OPHTHALMOSCOPE. 


THE     INDIRECT    METHOD    OF    OPHTHALMOSCOPIC 
EXAMINATION. 

When  the  eye  is  viewed  with  the  ophthalmoscope  from 
a  distance  greater  than  that  of  the  point  of  reversal,  the 
image  obtained  is  always  ari  inverted  image.  In  the 
shadow-test  that  image  is  not  accurately  focussed,  so  that 
the  relations  of  its  different  portions  are  not  recognized, 
as  in  the  ordinary  ophthalnioscopic  examination.  If, 
however,  the  myopia  be  of  high  degree,  so  that  the  in- 
verted image  is  formed  close  to  the  eye,  it  may  be  viewed 
from  some  little  distance,  where  it  can  be  focussed  and 
seen  distinctly,  so  that  not  only  the  different  portions  are 
recognized,  but  any  marked  anomaly  or  evidence  of  dis- 
ease can  be  studied. 

If  the  eye  be  not  myopic,  by  placing  2  to  3  inches  be- 
fore it  a  very  strong  convex  lens  (12.  to  20.  D.)  called  the 
object-lens,  an  inverted  image  of  the  fundus  can  be  formed. 
The  surgeon's  eye  must  be  placed  beyond  this,  far  enough 
to  focus  it.  By  placing  the  object-lens  at  or  near  its  focal 
distance  in  front  of  the  eye,  the  pupil  is  so  magnified  that 
it  appears  to  occupy  the  greater  part  of  the  object-lens, 
enabling  the  surgeon  to  see  a  considerable  part  of  the 
fundus  at  once.  With  a  2-inch  object-lens,  the  lens 
\vould  be  2  inches  in  front  of  the  eye,  and  the  image 
formed  about  2  inches  in  front  of  it.  Then  the  surgeon 
must  place  his  eye  far  enough  away  to  focus  this  image, 
say  12  inches  from  it,  making  it  16  inches  from  the  eye 
under  observation.  This  distance  may  be  shortened  some- 
what by  placing  back  of  the  ophthalnioscopic  mirror  a 
convex  lens  of  from  3.  to  5.  D.  to  aid  the  surgeon's  power 
of  accommodation. 

In  the  indirect  method  a  larger  part  of  the  fundus  may 
be  seen  at  once,  so  that  it  is  easier  to  make  search  for 
gross  ophthalmoseopic  changes.  On  the  other  hand,  the 
image  of  the  fundus  thus  obtained  is  less  magnified  than 
that  studied  by  the  direct  method,  so  that  slight  lesions 
are  less  readily  recognized.  The  method  is,  therefore,  of 
use  for  the  purpose  of  making  a  general  survey  of  the 


INDIRECT  METHOD.  143 

fund  us,  after  which  a  more  careful  study  of  the  diseased 
portions  may  be  made  by  the  direct  method. 

BIBLIOGRAPHY. 

Anomalies  of  Accommodation  and  Refraction  of  the  Eye,  with  a 
Preliminary  Essay  on  Physiological  Dioptrics.  F.  C.  Bonders, 
650  pp.  The  New  Sydenham  Society,  London. 

The  Refraction  and  Accommodation  of  the  Eye  and  Their  Anom- 
alies, E.  Landolt.  Translated  by  C.  M.  Culver,  600  pp.  Young 
J.  Pentland,  Edinburgh.  J.  B.  Lippincott  Co.,  Philadelphia. 

The  Refraction  of  the  Eye.  G.  Hartridge.  P.  Blakiston,  Son  & 
Co.,  Philadelphia. 

Theory  of  Accommodation.  M.  Tscherning,  A.  Crzellitzer,  A.  E. 
Stadfelt,  and  C.  Hess.  "Ophthal.  Review,"  Feb.,  1897. 

Accommodation  Theories  of  Helmholtz  and  Tscherning.  P.  Smith. 
"Trans.  Ophthal.  Soc.  of  the  United  Kingdom,"  Nov..  1898. 

Accommodation  in  the  Animal  Kingdom.  Th.  Beer.  "Ophthal. 
Review,"  Sept.,  1898. 

Accommodation  in  the  Rabbit.  Priestley  Smith.  "Ophthal.  Re- 
view," Oct.,  1898. 

The  Comparative  Value  of  the  Mydriatics.  S.  D.  Risley.  "Trans. 
Amer.  Ophthal.  Soc.,"  1881. 

Value  of  Homatropin  in  Diagnosis  of  Ametropia.  E.  Jackson. 
"Trans.  Sec.  on  Ophthal.,  Amer.  Med.  Assoc.,"  1896. 

Strength  of  the  Different  Mydriatics  and  Myotics.  E.  Jackson. 
"Trans.  Sec.  on  Ophthalmol.,  Amer.  Med.  Assoc.,"  1895. 

Action  of  Scopolamin.  C.  A.  Oliver.  "Amer.  Jour,  of  the  Med. 
Sciences,"'  Sept.  and  Oct.,  1896. 

Skiascopy  and  Its  Practical  Application.  110  pp.  Edward  Jack- 
son. Edwards  &  Docker  Co.,  Philadelphia. 

Retinoscopy.  J.  Thorington.  72  pp.  P.  Blakiston,  Son  &  Co., 
Philadelphia. 

Auto-Skiascopy.     E.Jackson.     "Ophthalmic  Review,"  Aug.,  1897. 

Distance  Between  Surgeon  and  Patient  for  Accurate  Skiascopy.  E. 
Jackson.  "Ophthal.  Record,"  Dec.,  1898. 


144  PRESBYOPIA. 


CHAPTER  VII. 

ERRORS    OF    REFRACTION,  CYLINDRICAL    LENSES, 
PRESBYOPIA,  AND  THE  WEARING  OF  GLASSES. 

PRESBYOPIA. 

EVEN  with  the  emmetropic  eye,  increasing  rigidity  of 
the  crystalline  lens  diminishes  the  power  of  focussing  on 
the  retina  the  divergent  rays  that  come  from  near  objects. 
On  this  account  the  near  point  of  distinct  vision  recedes 
from  the  eye.  Reading  and  similar  near  work  become 
difficult,  and  later  impossible.  When  this  loss  of  accom- 
modation reaches  such  a  degree  as  to  interfere  with  the 
patient's  ordinary  occupation,  the  condition  is  called  pres- 
byopia or  old  sight. 

Presbyopia  begins  before  the  accommodation  is  so  far 
lost  as  to  absolutely  prevent  the  seeing  of  near  objects. 
The  ciliary  muscle,  like  other  muscles,  is  capable,  for 
brief  periods,  of  stronger  contraction  than  can  be  kept  up 
continuously.  An  eye  cannot  keep  up  for  continuous 
reading  the  effort  it  can  make  during  a  brief  test  to  as- 
certain the  near  point.  Usually  the  amount  of  accom- 
modation which  can  be  sustained  for  continuous  work  is 
about  two- thirds  of  the  total  accommodation  of  which 
the  eye  is  capable.  Hence  when  two-thirds  of  the  total 
accommodation  is  less  than  the  amount  required  for  near 
work,  presbyopia  begins,  and  the  aid  of  a  convex  lens  is 
required. 

The  symptoms  of  presbyopia  may  be  either  the  actual 
indistinctness  of  near  objects,  or  evidence  of  strain  after 
using  the  eye  for  near-seeing.  The  patient  finds  himself 
unable  to  read  fine  print  especially  at  night,  or  he  has  to 
hold  the  print  too  far  away.  Sometimes,  although  on  be- 

§  inning  near  work  the  sight  is  clear,  it  suddenly  becomes 
im  after  a  time,  the  print  seeming  to  run  together  or 
blur.     Then,  if  the  eyes  are  closed  for  an  instant,  the 
power  of  near-seeing  is  regained,  and  continues  for  some 


ERRORS  OF  REFRACTION.  145 

time,  when  it  again  fails  suddenly.  These  blurrings, 
which  are  due  to  sudden  involuntary  relaxation  of  the 
ciliary  muscle,  tend  to  become  more  frequent  the  longer 
the  eifort  is  continued.  They  may  also  occur  from  strain 
of  accommodation  in  connection  with  hyperopia  in  young 
persons.  More  frequently  before  there  is  any  actual  in- 
ability to  see  clearly  for  near  work,  there  come  evidences 
of  strain  from  its  performance.  After  reading  or  sewing, 
particularly  in  the  evening,  the  eyes  smart  or  burn,  or  the 
following  morning  they  look  red  ;  or  there  occur  repeated 
attacks  of  conjunctivitis. 

The  symptoms  of  presbyopia  usually  begin  between  the 
ages  of  forty  or  fifty  years.  They  begin  earlier  in  hyperopic 
eyes  which  are  compelled  to  use  part  of  their  accommodation 
for  the  correction  of  their  hyperopia.  In  myopic  eyes 
less  accommodation  is  required  for  near  vision,  and  pres- 
byopia begins  later.  If  the  degree  of  myopia  is  such  that 
ordinary  near-seeing  can  be  done  without  any  use  of  the 
accommodation,  presbyopia  never  occurs. 

Diagnosis. — Between  forty  and  fifty  years  of  age, 
symptoms  of  eye-strain  or  difficulty  of  near-seeing  grad- 
ually develop  and  increase.  Distant  vision  is  good  with- 
out glasses,  and  rendered  worse  by  them ;  near  vision  is 
improved  or  made  easier  by  convex  lenses. 

Treatment. — The  treatment  for  presbyopia  is  either 
abstinence  from  near  work  or  doing  it  only  with  such  aid 
from  convex  lenses  that  not  more  than  the  proper  pro- 
portion of  the  accommodation  need  be  used.  Ordinarily 
two-thirds  can  be  used,  but  some  patients  can  continu- 
ously use  three-fourths  of  their  accommodation.  Others, 
especially  younger  people,  cannot  safely  employ  more 
than  one-half. 

The  accommodation  is  measured  by  finding  the  short- 
est distance  at  which  the  finest  type  can  be  clearly  seen. 
A  near  vision  test-card  being  held  at  1 5  or  20  inches  from 
the  eye,  the  patient  is  asked  to  read  the  finest  type  he  can 
see.  If  he  reads  the  20-inch  (half-meter)  type,  the  card 
is  pushed  gradually  toward  him  until  he  can  no  longer 
see  it  clearly.  Its  distance  from  the  eye  is  then  meas- 
10 


146  TREATMENT. 

ured,  this  being  the  focal  distance  of  the  lens,  having  a 
focussing  power  equivalent  to  the  accommodation.  (See 
table  of  lenses  and  focal  distances,  page  118.)  To  get  the 
full  amount  of  accommodation,  the  patient  must  sometimes 
be  coaxed  to  make  a  special  effort. 

Having  ascertained  the  amplitude  of  accommodation, 
two-thirds  of  that  amount  must  be  subtracted  from  the 
focussing  power  required  for  near  work.  The  difference 
will  be  the  refractive  power  of  the  lens  needed  to  cor- 
rect the  presbyopia. 

For  example,  if  an  emmetropic  eye  can  read  the  20- 
inch  type  clearly  at  13  inches,  or  can  just  make  out  the 
13-inch  type  at  that  distance,  it  proves  clear  focussing  at 
13  inches,  the  focal  distance  of  a  3.  D.  lens.  The 
patient  then  has  3.  D.  accommodation.  Two-thirds  of 
this,  or  2.  D.,  is  what  we  may  expect  him  to  use  safely 
for  continuous  near  work.  Now  if  he  has  to  read  and 
write  at  a  distance  of  12  inches,  where  3.25  D.  of  focus- 
sing power  will  be  required,  he  must  make  up  the  dif- 
ference between  3.25  D.  and  2.  D.  or  1.25  D.  by  convex 
lenses  of  that  strength,  when  doing  near  work. 

The  following  table,  based  on  the  decline  of  accommo- 
dation, as  shown  in  the  table  on  page  126,  indicates  for 
different  ages  the  near-point  in  inches,  amplitude  of  ac- 
commodation in  diopters,  two-thirds  of  that  amplitude  or 
accommodation  available  for  near  work,  and  the  differ- 
ence between  the  available  accommodation  and  the  focus- 
sing power,  3.  D.,  required  to  correct  the  presbyopia  for 
that  working  distance. 

TABLE  V. — Accommodation  and  Lenses  for  Presbyopia. 


Age. 

Near-Point. 

Total  Accom. 

Available  A. 

Lens  Required. 

40  . 

.    7  in. 

5.5  D. 

3.67 

0. 

45 

.  10  in. 

4.  D. 

2.67 

0.50 

50  . 

.  16  in. 

2.5  D. 

1.67 

1.50 

55 

.  31  in. 

1.25 

0.83 

2.25 

60  . 

.  78  in. 

0.5 

.33 

2.75 

65  . 

.  00 

0. 

0. 

3. 

Such  a  table  should  never  be  used  for  prescribing  glasses, 
for  it  only  represents  an  average,  from  which  the  particu- 


PRESBYOPIA.  147 

lar  case  may  differ  greatly.  Neither  should  glasses  be 
prescribed  in  any  way  from  the  age  of  the  patient,  for 
besides  individual  variation  in  the  loss  of  accommodation, 
hyperopia  and  myopia  influence  the  glass  required,  and 
must  always  be  considered.  Nor  can  the  glasses  required 
for  presbyopia  be  guessed  at  from  the  blurring  of  the 
patient's  vision,  since  this  depends  as  much  on  the  size  of 
the  pupil  as  upon  the  perfection  of  the  focussing.  In 
every  case  the  total  accommodation  should  be  ascertained 
by  the  determination  of  the  refraction  of  the  eye  and  its 
near-point  of  distinct  vision.  If  the  patient  has  some 
working  distance  other  than  one-third  of  a  meter — 13 
inches — the  available  accommodation  must  be  deducted 
from  the  focussing  power  required  for  that  distance,  to 
find  the  lens  required.  Presbyopia  complicated  by  hyper- 
opia or  myopia  is  discussed  in  connection  with  their 
treatment. 

Prognosis. — Presbyopia  continues  to  increase  until  all 
power  of  accommodation  is  lost,  at  the  age  of  fifty-five  or 
sixty.  Until  this  time  the  lenses  given  to  correct  it  should 
be  changed  every  two  or  three  years.  After  that  age 
no  change  of  lenses  may  be  required  for  several  years. 

HYPEROPIA. 

Hyperopia  (hypermetropia  or  far-sight]  is  the  most 
common  error  of  refraction,  being  present  in  about  70 
per  cent,  of  all  eyes.  To  the  savage  it  is  far  less  dan- 
gerous than  myopia,  which  lessens  his  power  to  secure 
food  and  guard  against  enemies.  But  with  civilization 
and  the  general  employment  of  the  eyes  for  near  work, 
hyperopia  becomes  a  serious  defect. 

The  hyperopic  eye  refracts  parallel  rays  toward  a  point 
behind  the  retina ;  the  retina  is  in  front  of  the  principal 
focus  of  the  dioptric  media.  The  hyperopic  eye  is  rela- 
tively too  short,  either  because  its  refracting  surface  is 
not  sufficiently  curved,  hyperopia  of  curvature;  or  be- 
cause its  anteroposterior  axis  is  actually  shorter  than  that 
of  the  average  eyeball,  axial  hyperopia.  In  the  majority 


148  OPTICAL  NATURE. 

of  cases  the  latter  is  the  condition  present ;  and  in  high 
hyperopia  the  eyeball  may  be  noticeably  small  in  all  its 
dimensions,  so  that  it  does  not  properly  fill  the  orbit. 
The  course  of  the  rays  in  the  hyperopic  eye  is  shown 
in  Fig.  61  ;  parallel  rays  passing  in  the  course  of  the 


FIG.  61. — Course  of  rays  in  the  hyperopic  eye,  with  and  without  the  correcting 

lens. 

broken  lines  would  be  focussed  at  F,  back  of  the  retina.  To 
cause  the  rays  to  be  focussed  on  the  retina  they  must  be 
given  a  certain  amount  of  convergence  before  they  reach 
the  eye ;  they  must  be  turned  in  the  direction  of  the 
dotted  lines  toward  jR.  R  is  called  the  far-point  of  the 
hyperopic  eye.  It  is  a  kind  of  "  virtual "  far-point, 
situated  behind  the  eye.  It  is  the  principal  focus  of  the 
lens  L  that  will  correct  the  hyperopia.  When  rays  are 
converged  toward  it,  the  refractive  power  of  the  eye  is 
sufficient  to  focus  them  on  the  retina,  as  shown  by  the 
solid  lines. 

Rays  emerging  from  a  point  of  the  retina  of  the 
hyperopic  eye  traverse  the  same  path  in  the  opposite 
direction.  As  they  pass  out  of  the  cornea  they  are  not 
rendered  parallel,  but  still  diverge  as  though  they  came 
from  the  "  far-point "  of  the  eye  R ;  and  they  require  a 
convex  lens  L,  with  its  principal  focus  at  R,  to  make  them 
parallel.  If  the  lens  be  placed  at  the  eye,  its  focal  dis- 
tance will  be  the  distance  of  the  far-point  back  of  the 
eye ;  but  if  the  lens  be  placed  in  front  of  the  eye,  its  focal 
distance  must  be  proportionately  increased.  Thus,  if  the 
far-point  be  4  inches  back  of  the  cornea,  the  focal  distance 
of  a  correcting  lens  placed  at  the  cornea  must  be  4  inches 
(10.  D.  lens);  but  if  the  lens  be  placed  ^  inch  in  front 
of  the  cornea,  its  focal  distance  must  be  4^  inches  (9.  D. 


HYPEROPIA.  149 

lens).  Either  of  these  lenses  at  its  proper  distance  from 
the  eye  will  render  clear  distant  objects  as  test-letters ;  or 
it  will  render  parallel  the  rays  that  pass  from  the  patient's 
retina  to  the  surgeon's  eye  through  the  ophthalmoscope. 
Hyperopia  may  also  be  usually  corrected  by  the  proper 
amount  of  accommodation,  having  the  effect  of  a  convex 
lens. 

Causes. — Hyperopia  is  due  to  a  congenital  departure 
from  the  proportions  of  the  emmetropic  eye,  or  it  may  arise 
from  the  removal  of  the  crystalline  lens,  or  cicatrical  flat- 
tening of  the  cornea.  • 

Varieties. — The  theoretical  varieties,  hyperopia  of 
curvature  and  axial  hyperopia,  have  been  mentioned. 
The  chief  clinical  varieties  depend  on  the  relations  of 
the  hyperopia  to  the  accommodation.  When  the  accom- 
modation is  entirely  relaxed,  as  under  the  influence  of  a 
cycloplegic,  all  the  hyperopia  is  revealed.  This  is  the 
total  hyperopia.  When  the  hyperopia  is  so  great  that  the 
maximum  exertion  of  the  accommodation  leaves  part  of 
it  uncorrected,  this  part  is  called  the  absolute  hyperopia. 
When,  as  frequently  happens,  the  habit  of  correcting 
hyperopia  by  accommodation  is  so  strong  that  it  is  impos- 
sible for  the  patient  to  look  at  even  a  distant  object  with- 
out using  some  accommodation,  although  he  may  have  a 
convex  lens  before  the  eye  that  renders  accommodation 
unnecessary,  the  part  of  the  hyperopia  he  cannot  help 
correcting  is  called  the  latent  hyperopia.  All  the  hyperopia 
that  is  not  latent  is  the  manifest  hyperopia.  That  part  of 
hyperopia  between  the  latent  and  the  absolute,  the  part  that 
can  be  corrected  by  the  accommodation  or  left  uncorrected 
at  pleasure,  is  the  facultative  hyperopia.  The  relations  of 
these  different  varieties  to  each  other  and  to  the  voluntary 
and  involuntary  accommodation  are  shown  in  the  follow- 
ing diagram  : 


Total  Acco 
Involuntary  A. 

mmodation. 
Voluntary  A. 

Latent  II. 
T 

Facultative  H. 
Man 
o  tal      Hy  pe  r  opi 

Absolute  H. 
ifest  H. 
a  . 

150  VARIETIES. 

On  trying  convex  lenses  before  an  eye  which  presents 
all  these  varieties  of  hyperopia,  commencing  with  a  weak 
lens,  vision  is  improved  as  the  lens  is  made  stronger  until 
all  the  absolute  H.  is  corrected  ;  when  with  the  aid  of  all 
the  accommodation  the  full  vision  may  be  obtained.  In- 
creasing the  strength  of  the  lens  yet  further,  the  full 
vision  is  still  obtained,  but  with  less  effort  of  accommoda- 
tion until  all  of  the  facultative  H.  is  corrected,  no  volun- 
tary accommodation  being  needed.  But  on  still  increasing 
the  strength  of  the  lens  distant  vision  gets  worse,  since 
the  accommodation  cannot  be  further  relaxed ;  and  a  part 
of  the  latent  H.  is  doubly  corrected,  making  the  eye  to 
that  extent  near-sighted. 

In  early  life  none  is  absolute  unless  the  total  hyperopia  is 
of  very  high  degree.  After  fifty  or  fifty-five  it  all  becomes 
absolute.  Before  fifty,  hyperopia  is  partly  latent  in  about 
one-third  of  all  cases,  when  both  eyes  are  tested  together. 
When  each  eye  is  tested  separately,  a  much  higher  pro- 
portion fail  to  manifest  all  their  H.  H.  is  more  apt  to 
become  latent  when  the  eyes  have  been  strained  or  irri- 
tated ;  and  the  proportion  that  is  latent  may  vary  greatly 
from  day  to  day,  or  even  in  a  few  minutes. 

Symptoms. — In  early  childhood,  hyperopia  causes  con- 
vergent squint, which  arises  in  the  larger  number  of  cases 
before  six  years  of  age.  Squint  may  be  associated  with 
any  degree  of  H. ;  but  it  is  a  high  degree  of  H.,  2.  to  6. 
D.,  though  not  the  highest  degree,  that  most  frequently 
causes  squint.  Squint  due  to  H.  is  very  often  variable  in 
degree  or  intermittent. 

Hyperopia  becomes  a  cause  of  eye-strain.  When  the 
eyes  begin  to  be  much  used  for  reading,  looking  at  pictures, 
etc.,  there  arises  chronic  hyperemia  of  the  conjunctiva  and 
lid-margins.  Later,  as  puberty  is  approached,  headache 
becomes  an  important  symptom.  From  that  time  up  to 
middle  life,  hyperopia,  with  or  without  astigmatism,  con- 
tinues to  be  the  most  frequent  and  most  important  cause 
for  headache.  Later,  H.  gives  rise  to  the  symptoms  of 
presbyopia,  coming  on  some  years  earlier  than  it  other- 
wise would. 


HYPEROPIA.  151 

Headaches  caused  by  hyperopia  are  not  peculiar  to 
that  condition ;  but  are  similar  to  headaches  from  loss 
of  sleep,  exhaustion,  anemia,  etc.  The  pain  is  most 
frequently  quite  dull  and  confined  to,  or  most  severe  in, 
the  frontal  region.  It  may  be  constant  (usually  with  ex- 
acerbations of  greater  severity),  may  be  felt  only  at  such 
times  as  the  eyes  have  been  much  used  for  near  work,  or 
it  may  take  the  form  of  distinct  attacks  of  migraine.  In 
some  cases  the  periods  of  its  occurrence  are  periods  of 
specially  hard  use  of  the  eyes;  in  others  they  are  the 
menstrual  periods,  or  any  time  of  nerve-exhaustion.  In 
some  cases  the  headaches  cease  as  soon  as  the  H.  is  cor- 
rected, or  the  eyes  are  placed  under  the  influence  of  a 
cycloplegic ;  in  others  they  disappear  quite  gradually,  or 
only  after  improvement  of  the  general  health. 

Imperfect  distant  vision  from  hyperopia  alone  is 
uncommon  in  early  life,  and  is  only  met  with  when  the 
H.  is  very  high.  Cases  of  this  kind  are  frequently  mis- 
taken for  cases  of  myopia.  The  child  inclines  to  hold 
things  very  close  because  of  his  imperfect  vision,  and 
by  holding  the  object  very  near  he  gets  a  large  retinal 
image.  Then  his  strong  convergence  is  accompanied 
with  a  strong  contraction  of  the  pupil,  which  renders  his 
retinal  images  less  indistinct.  When  the  power  of 
accommodation  has  been  lost,  even  the  lowest  degrees  of 
H.  will  render  vision  imperfect.  When  the  eyes  are 
used  much  for  near  work,  even  early  in  life,  moderate 
degrees  of  H.  are  liable  to  cause  sudden  failure  of 
accommodation,  particularly  toward  the  latter  part  of 
the  day.  This  has  been  mentioned  as  a  symptom  of 
presbyopia. 

The  severity  of  the  symptoms  of  hyperopia  gives  little 
indication  of  the  degree  of  the  defect.  One  person  with 
high  H.  may  go  until  nearly  forty  with  no  serious  incon- 
venience ;  while  another,  with  much  less,  is  compelled  to 
wear  glasses  constantly  from  childhood.  Symptoms  are 
likely  to  arise  first  when  the  eyes  have  been  subjected  to 
some  special  strain  of  near  work,  as  during  term  exam- 


152  SYMPTOMS. 

inations  at  school ;  or  they  may  appear  after  an  attack 
of  acute  illness,  like  influenza  or  typhoid  fever. 

Diagnosis. — Distant  vision  is  often  very  good,  if  the 
accommodation  be  sufficient.  If  vision  be  imperfect,  it 
will  be  improved  on  looking  through  the  pinhole  disk. 
Near  vision  is  relatively  the  worse.  The  near-point  of 
distinct  vision  is  not  so  close  as  it  should  be  at  the 
patient's  age.  Vision  is  not  impaired  by  convex  lenses 
unless  they  are  too  strong.  With  the  ophthalmoscope  the 
fundus  is  clearly  seen  without  a  lens,  or  with  a  convex 
lens.  By  skiascopy  an  erect  image  (movement  "  with  " 
light  on  the  face  with  plane  mirror)  is  obtained  through 
a  convex  lens,  beyond  the  focal  distance  of  the  lens.  The 
amount  of  H.  is  to  be  measured  as  described  on  page  139. 

With  test  lenses,  if  the  power  of  accommodation  has 
been  removed  by  age  or  the  use  of  a  mydriatic,  each  eye 
should  be  tested  alone.  The  convex  lens  giving  the 
best  distant  vision  will  be  the  one  which  focusses  on  the 
retina  rays  from  the  test-object.  If  the  test-object  is  4 
meters  away,  the  rays  from  it  are  0.25  D.  divergent,  and 
truly  parallel  rays  would  be  focussed  on  the  retina  by  a 
lens  0.25  D.  weaker.  This  0.25  D.  must  therefore  be 
subtracted  from  the  lens  chosen  at  4  meters  to  find  the 
true  correction  of  the  hyperopia.  With  the  test-type  at 
6  meters  the  theoretical  deduction  would  be  one-sixth  of 
a  diopter. 

When  the  accommodation  is  active,  the  hyperopia  is 
best  measured  by  testing  both  eyes  together.  Begin  by 
placing  before  them  convex  lenses  strong  enough  to 
somewhat  blur  distant  vision.  Then  gradually  weaken 
these,  by  holding  successively  stronger  concave  lenses 
before  them,  or  by  replacing  by  weaker  convex  lenses. 
Care  must  be  taken  not  to  allow  the  patient  to  look  at  the 
test-type  without  glasses,  and  thus  bring  the  accommoda- 
tion into  active  use.  When  good  vision  has  thus  been 
obtained,  cover  one  eye  and  then  the  other  ;  if  the  vision 
of  one  eye  is  still  imperfect,  make  the  convex  lens  before 
it  still  weaker,  until  vision  is  as  good  as  that  of  the 
other  eye,  or  is  not  further  improved  by  the  weaken- 


HYPEROPIA.  153 

ing  of  the  glass.  This  method  presupposes  that  each  eye 
is  capable  of  good  vision,  and  is  free  from  astigmatism, 
or  has  it  already  corrected. 

Treatment. — Hyperopia  of  itself  requires  no  treat- 
ment. Most  eyes  that  do  the  moderate  work  required  of 
them,  without  damage  or  inconvenience  to  their  possessors, 
have  hyperopia  of  low  degree ;  but  whenever  symptoms 
liable  to  arise  from  H.  occur,  the  probability  of  their 
being  due  to  it  is  to  be  considered,  and  the  standard  ther- 
apeutic resources  will  not  have  been  employed  without 
use  of  proper  correcting  glasses.  For  headache  and  conges- 
tion or  inflammation  of  the  eyes  or  lids,  the  correcting 
lenses  should  be  worn  constantly.  Where  no  incon- 
venience is  experienced  except  in  direct  connection  with 
use  of  the  eyes  for  near  work,  the  glasses  may  be  worn 
for  near  work  only.  In  exceptional  cases  where  the 
hyperopia  is  high,  and  the  symptoms  it  causes  are  insig- 
nificant and  only  connected  with  near  work,  a  partial  cor- 
rection may  be  worn  at  such  times. 

Sometimes  the  full  correction  of  the  hyperopia,  in 
young  persons  who  have  some  of  that  hyperopia  latent, 
causes  at  first  blurring  of  distant  objects.  If  the  glasses 
have  been  correctly  chosen,  this  blurring  will  pass  away 
after  a  time,  the  H.  becoming  all  manifest.  Sometimes 
this  requires  several  weeks,  in  other  cases  it  requires  but 
a  few  hours.  It  indicates  an  improper  activity  of  the 
ciliary  muscle,  which  passes  away  with  the  wearing  of 
glasses,  or  more  quickly  by  the  use  of  a  cycloplegic. 
Until  it  is  overcome,  the  eye  cannot  be  regarded  as  quite 
well,  and  the  full  benefit  of  the  glasses  will  not  be  expe- 
rienced. The  patient  should  be  previously  warned  that 
this  may  occur  when  the  glasses  are  first  worn,  or  whenever 
the  eyes  are  particularly  tired  or  irritated  ;  and  that  it  is 
an  indication,  not  for  removal  of  the  glasses,  but  rather 
for  the  steady  wearing  of  them,  with  lessening  of  the  near 
work  required  of  the  eyes. 

It  is  generally  easier  for  the  eyes  to  become  accustomed 
to  the  full  correction  than  to  a  partial  correction  that  in- 
cludes some  of  the  latent  H. ;  and  those  cases  that  have 


154  TREATMENT. 

the  most  trouble  in  becoming  accustomed  to  the  full  cor- 
rection often  experience  the  greatest  benefit  from  it.  If 
it  is  known  that  the  patient,  even  after  an  explanation  of 
the  difficulty,  will  not  wear  correcting  lenses  long  enough 
or  steadily  enough  to  get  the  benefit  of  them,  a  partial 
correction  of  the  hyperopia  may  be  prescribed,  with  the 
warning  that  the  glasses  will  soon  need  to  be  changed  and 
that  full  relief  may  not  be  secured  until  the  full  cor- 
rection is  worn.  The  full  correction  of  hyperopia  will 
not  be  satisfactory  unless  the  glasses  at  the  same  time  ac- 
curately correct  any  astigmatism  present  and  any  differ- 
ence of  refraction  between  the  two  eyes. 

When  the  hyperopic  eye  becomes  also  presbyopic,  the 
glasses  that  correct  the  hyperopia  and  serve  for  far  seeing 
will  not  be  sufficient  for  near  work,  for  which  another 
pair  of  lenses  must  be  worn.  The  glasses  for  near  work 
may  be  determined  by  placing  on  the  patient  the  lenses 
correcting  his  H.,  and  with  them  determining  the  near 
point,  and  from  it  the  correction  for  presbyopia,  to  be 
added  to  the  correction  for  H.  for  continuous  near  work. 
Or  one  may  determine  the  "  near  point "  directly,  without 
glasses,  and  from  it  and  the  known  hyperopia  calculate 
the  glasses  that  will  enable  the  patient  to  work  at  the  re- 
quired distance  without  using  more  than  two-thirds  of  his 
accommodation. 

Prognosis. — At  birth  almost  all  eyes  are  hyperopic, 
and  during  early  childhood  some  become  less  hyperopic,  and 
some  even  myopic.  But  from  the  age  of  fifteen  years  the 
general  tendeny  is  for  H.  to  increase,  probably  by  the  slow 
growth  of  the  crystalline  lens,  which  continues  until  old  age. 
As  the  lens  increases  in  all  dimensions,  its  focus  lengthens. 
In  early  adult  life  the  increase  of  H.  is  usually  very 
slight;  but  it  is  often  more  rapid  after  middle  age.  In 
extreme  old  age  hyperopia  may  diminish  through  changes 
in  the  crystalline  lens.  No  definite  opinion  can  be  given 
as  to  how  often  glasses  correcting  hyperopia  require  to  be 
changed.  Usually  it  is  not  for  several  years,  sometimes 
many  years,  but  occasionally  within  a  year  or  two.  The 
hyperopia  following  the  extraction  of  the  crystalline  lens 


HYPEROPIA.  155 

generally  increases  markedly  for  several  months  after  the 
operation. 

MYOPIA. 

Myopia  (brachymetropia,  short  sight  or  near  sight)  is 
extremely  rare  among  savages.  But  it  is  quite  common 
among  civilized  people,  arising  as  the  result  of  disease 
caused  or  favored  by  the  overuse  and  strain  of  the  eyes  for 
near  seeing.  It  is  most  frequent  among  students  and 
others  who  lead  sedentary  lives  and  do  much  close  eye- 
work,  such  as  tailors,  dressmakers,  etc. ;  while  among 
outdoor  laborers,  farmers,  and  sailors,  it  is  comparatively 
rare. 

The  myopic  eye  focusses  parallel  rays  in  front  of  its 
retina,  the  retina  is  behind  the  principal  focus  of  the 
dioptric  surfaces.  It  is  relatively  too  long,  either  because 
the  refracting  surfaces  are  too  much  curved — myopia  of 
curvature;  or  because  the  antero-posterior  axis  of  the 
eyeball  is  really  longer  than  it  should  be — axial  myopia. 
Usually  the  myopia  is  axial,  having  been  caused  by  the 
yielding  of  the  sclero-corneal  coat  to  the  intra-ocular 
pressure.  When  the  myopia  is  very  high  in  degree,  the 
enlargement  of  the  eyeball  causes  it  to  fill  the  orbit  and 
protrude,  making  the  eye  prominent.  The  course  of  rays 
in  the  myopic  eye  is  illustrated  in  Fig.  62.  Parallel  rays, 


R.. 


FIG.  62.— Course  of  rays  entering  the  myopic  eye,  with  and  without  correcting 

lens. 

entering  in  the  direction  of  the  broken  lines,  are  brought 
to  a  focus  within  the  vitreous ;  and  when  they  reach  the 
retina  they  have  become  divergent  again,  so  that  distinct 
distant  vision  is  impossible.  Rays  with  a  certain  amount 
of  divergence,  coming  from  Rt  the  point  for  which  the 


156  OPTICAL  'NATURE. 

eye  is  optically  adjusted — the  far-point  of  the  eye — are 
accurately  focussed  on  the  retina.  To  focus  parallel  rays 
on  the  retina  it  is  necessary  to  place  before  the  eye  a 
concave  lens  that  will  cause  them  to  diverge,  as  though 
they  came  from  the  far-point  R.  Rays  emerging  from  a 
point  in  the  retina  of  the  myopic  eye,  traversing  the  same 
path  in  the  opposite  direction,  leave  the  cornea  turned 
toward  the  far- point  R.  They  require  a  concave  lens 
having  its  principal  focus  at  R  to  make  them  parallel. 

Myopia  is  "  corrected "  by  a  concave  lens  having  its 
principal  focus  at  the  far-point  of  the  myopic  eye.  The 
distance  of  the  far-point  from  the  eye  will  be  the  focal 
distance  of  the  lens,  which,  when  placed  at  the  eye,  will 
correct  the  myopia.  But  if  the  lens  be  placed  in  front 
of  the  eye,  nearer  the  far-point,  its  focal  distance  will 
have  to  be  to  that  extent  shorter.  Suppose  the  far-point 
to  be  3  inches  in  front  of  the  eye.  If  the  lens  be  placed 
at  the  eye,  a  3-inch  (13.  D.)  lens  will  correct  the  myopia. 
But  if  placed  a  half-inch  in  front  of  the  eye,  the  correcting 
lens  will  be  only  2|-  inches  from  the  far-point,  and  a  2^ 
inch  (15.  D.)  lens  will  be  required  to  correct  the 
myopia. 

The  myopic  eye  is  unable  to  correct  its  defect  by 
accommodation.  When  the  accommodation  is  exerted, 
the  focus  of  the  parallel  rays  is  brought  still  farther  in 
front  of  the  retina,  and  rays  to  be  focussed  on  the  retina 
must  reach  the  eye  still  more  divergent.  It  can  see  dis- 
tinctly closer  than  the  ernmetropic  eye  of  the  same  age, 
and  thus  has  some  of  the  advantage,  as  well  as  the  disad- 
vantages, of  an  eye  with  a  magnifying  glass  before  it. 

Causes  and  Course. — Myopia  is  due  chiefly  to  the 
straining  of  the  eyes  for  near  work.  There  seem  to  be 
two  important  factors  in  its  production — namely,  soften- 
ing of  the  scleral  coat  by  congestion,  and  pressure  of  the 
muscles  around  the  eyes  in  fixing  near  objects.  These 
co-operate  with  the  normal  intra-ocular  tension  to  pro- 
duce stretching  of  the  sclero-corneal  coat,  at  the  region  of 
greatest  softening  and  least  resistance,  usually  about  the 
posterior  pole  of  the  eye,  or  the  entrance  of  the  optic 


MYOPIA.  157 

nerve.  An  important  cause  of  eye-strain  and  myopia  is 
astigmatism.  Sometimes  the  initial  softening  of  the 
sclera  occurs  as  a  result  of  acute  general  disease,  as  after 
one  of  the  eruptive  fevers ;  and  vascular  tension  has  been 
credited  with  an  important  influence  in  causing  it. 

The  process  of  distention,  beginning  in  hyperopic  eyes, 
leads  first  to  diminished  hyperopia,  and  later  to  myopia. 
In  its  earlier  stages  it  is  often  arrested  by  diminished  strain 
of  the  eyes  on  account  of  pain,  or  other  symptoms  of 
irritation  that  arise.  If  the  distention  and  the  thinning 
of  the  sclera  have  not  progressed  too  far,  the  normal  in- 
creasing rigidity  of  the  sclera  tends  to  arrest  it  in  early 
adult  life.  Often  when  one  eye  is  practically  useless,  and 
convergence  to  secure  binocular  vision  is  given  up,  the 
increase  of  myopia  ceases.  But  generally  the  more  the 
sclera  is  thinned  the  more  rapidly  does  it  continue  to 
yield  to  intra-ocular  pressure,  until  extreme  myopia  ter- 
minates in  blindness,  by  vitreous  opacities,  atrophy  of  the 
choroid,  or  detachment  of  the  retina. 

As  myopia  "increases,  a  viscous  circle  is  established.  The 
patient  is  disabled  for  distant  seeing,  and  uses  his  eyes 
more  and  more  for  near  work.  At  the  same  time  near 
work  becomes  harder  and  more  dangerous,  because  of  the 
change  in  shape  of  the  eyeball.  The  normal  eye  is  a 
sphere,  turning  in  a  spherical  socket,  equally  well  in  all 
directions.  In  high  myopia  the  eyeball  always  becomes 
more  or  less  ovoid,  lying  in  the  space  included  by  the 
cone  of  muscles  that  arise  from  the  apex  of  the  orbit  and 
pass  forward  to  be  attached  to  its  anterior  segment.  This 
ovoid  eyeball  fits  in  its  socket  only  in  one  direction.  If 
turned  from  this  direction  it  must  push  aside  the  tissue 
composing  its  socket,  or  be  compressed  by  it.  The  ovoid 
socket  having  the  direction  of  the  muscular  cone,  and  the 
visual  axis  being  nearly  in  the  direction  of  the  long  axis 
of  the  eyeball,  there  is  almost  always  a  tendency  for 
highly  myopic  eyes  to  diverge.  Because  of  this  tendency 
to  divergence,  and  the  necessity  of  excessive  convergence 
for  binocular  vision  at  the  only  distance  at  which  clear 
vision  is  possible,  the  myopic  eye  is  subjected  to  excessive 


158  CAUSES  AND  COURSE. 

effort  of  convergence,  with  increased  pressure  on  the 
sides  of  the  globe,  tending  to  distend  it  still  further 
anteroposteriorly.  This  injurious  influence  continues 
active  until  the  need  for  excessive  convergence  is  removed 
by  the  wearing  of  glasses,  or  until  binocular  vision  ceases, 
either  by  the  practical  blindness  of  one  eye  or  by  its 
actual  divergence — divergent  squint. 

Varieties. — Besides  axial  myopia  and  myopia  of 
curvature  (see  p.  155),  theoretically  there  might  be  added 
myopia  due  to  changes  in  the  index  of  refraction  of  one 
or  more  of  the  dioptric  media.  The  temporary  myopia 
referred  to  as  a  sequel  of  iritis  (Chapter  XI)  has  been 
ascribed  to  this  cause  ;  and  the  myopia  which  comes  on  in 
old  age,  often  as  a  forerunner  of  cataract,  is  due  to  in- 
crease in  the  refraction  of  the  lens  nucleus.  Progressive 
myopia  is  a  term  that  would  apply  to  all  cases  of  M.  at 
some  stage.  But  it  is  usually  intended  to  imply  that  the 
case  continues  progressive  while  under  observation. 
Malignant  myopia  is  applied  to  a  small  group  of  cases 
which,  in  spite  of  treatment  and  avoidance  of  near  work, 
continue  to  go  steadily  from  bad  to  worse  until  all  useful 
vision  is  lost.  The  same  term  is  sometimes  applied  to 
any  case  that  has  gone  so  far  that  there  remains  but  little 
sight,  and  little  to  expect  from  treatment,  although  such 
a  condition  may  have  been  produced  only  by  reckless 
disregard  of  all  hygienic  measures. 

It  is  also  convenient  to  classify  myopia  according  to  its 
degree  as  follows  :  Low  M.,  not  over  2.  D.,  some  accom- 
modation being  required  for  most  kinds  of  near  work. 
Moderate  M.,  from  2.  D.  to  4.  D.,  near  work  being  pos- 
sible without  accommodation  and  without  excessive  con- 
vergence. High  M.,  from  4.  to  10.  D.,  binocular  vision 
being  still  possible  but  with  excessive  convergence.  Very 
high  M.,  over  10.  D.,  binocular  vision  being  usually 
impossible  without  concave  lenses. 

Symptoms. — Myopia  always  causes  impairment  of 
distant  vision.  In  a  few  cases  this  impairment  has  not 
been  noticed  until  the  eyes  come  to  be  tested  ;  but  gener- 
ally it  is  the  first  thing  to  attract  attention,  and  is  usually 


MYOPIA.  159 

quite  striking.  It  depends  on  the  degree  of  the  myopia 
and  size  of  the  pupil,  which  is  often  rather  large  in 
myopic  eyes,  and  on  retinal  lesions  that  accompany  the 
myopia.  In  any  case  the  near  vision  is  comparatively 
good,  and  the  near- point  closer  to  the  eye  than  normal. 

With  high  myopia  the  impairment  of  vision  prevents 
the  patient  from  recognizing  and  imitating,  or  responding 
to  the  facial  expression  of  others.  Hence,  the  face  of  the 
myope  often  looks  dull,  unresponsive,  or  expressionless. 
When  trying  to  see  distant  objects  clearly,  the  myope 
almost  closes  the  lids,  to  narrow  the  circles  of  diffusion 
on  the  retina.  This  habitual  "  nipping"  of  the  lids  also 
affects  the  facial  expression,  and  gave  rise  to  the  term 
myopia.  Imperfect  distant  vision  gives  a  distaste  for 
outdoor  sports  that  require  good  sight,  excludes  from 
certain  occupations,  and  turns  the  patient  to  sedentary  pur- 
suits requiring  distinct  vision  at  short  distances  only. 
These  symptoms  disappear  when  correcting  glasses  are 
worn  continuously. 

The  difficulty  of  turning  the  ovoid  myopic  eye  in  its 
socket  causes  the  patient  partly  to  substitute  movements 
of  the  head  and  body  for  those  of  the  eyes.  This  causes 
a  peculiar  carriage  of  the  head  when  walking,  and  a 
characteristic  attitude  and  movement  of  the  head  in  read- 
ing. Instead  of  holding  the  head  and  book  still,  and  fol- 
lowing each  line  by  a  movement  of  the  eyes,  the  whole 
head  is  turned  somewhat,  from  side  to  side,  the  book 
being  at  the  same  time  moved  in  the  opposite  direction. 
These  movements  are  greatly  exaggerated  when  the 
patient  reads  without  glasses,  because  of  the  greater  angle 
subtended  by  the  line  when  held  very  close  to  the  eye. 
If  the  book  or  other  object  looked  at  is  too  heavy  to  raise 
to  the  eyes,  the  head  is  bent  down  toward  it,  interfering 
with  the  return  of  venous  blood  in  the  neck,  and  favoring 
congestion  of  the  head  and  eyes.  The  connection  of 
divergent  squint  with  myopia  is  farther  considered  in 
Chapter  VIII. 

The  difficulty  of  executing  ocular  movements  may  cause 
frequent  and  severe  aching  in  the  eyes,  besides  the  head- 


160  SYMPTOMS. 

aches  which  may  occur  in  connection  with  myopia,  as 
with  hyperopia  or  astigmatism,  through  eye-strain.  It 
should  be  noted  that  with  myopia,  although  near  vision 
without  accommodation  is  theoretically  possible,  it  is  not 
usually  accomplished  in  practice.  The  difference  in  the 
degree  of  M.  between  the  eyes,  and  the  strong  effort  of 
convergence  required,  nearly  always  provoke  some  effort 
of  accommodation,  and  a  slight  inaccuracy  in  the  distance 
of  the  near  work  may  compel  as  much  accommodation  as 
the  emmetropic  eye  is  usually  required  to  exert.  Thus, 
a  myope  having  M.  of  10.  D.,  holding  his  book  1  inch 
nearer  his  eyes  than  necessary,  would  need  to  use  3.  D. 
of  accommodation — the  same  as  an  emmetrope  reading  at 
13  inches. 

The  occurrence  of  muscse  volitantes  with  myopia  has 
already  been  alluded  to  (p.  42).  Moving  clouds  before 
the  sight  may  indicate  the  presence  of  vitreous  opacities 
of  any  size.  They  usually  appear  rather  suddenly  after 
some  especial  strain  of  the  eye.  With  the  ophthal- 
moscope the  opacities  may  be  identified,  and  their  progress 
watched.  If  large  they  rarely  disappear  entirely,  although 
they  become  less  annoying.  The  tendency  is  for  the 
vitreous  slowly  to  become  more  disorganized  and  fluid, 
the  opacities  becoming  more  freely  movable,  even  though 
the  degree  of  myopia  be  not  increasing. 

Cataract  occurs  ultimately  in  a  large  proportion  of 
highly  myopic  eyes.  It  is  apt  to  be  of  slow  develop- 
ment and  dark  in  color — the  so-called  choroidal  cataract. 
Posterior  polar  cataract  is  sometimes  seen  in  myopic  eyes 
for  many  years  before  there  is  any  general  opacity  of  the 
lens. 

Choroidal  changes  almost  invariably  mark  the  progress 
of  myopia.  They  begin  usually  with  haziness  or  a  fluffy 
appearance,  which  is  often  confined  to  the  temporal  side 
of  the  optic  disk,  but  may  be  more  general.  Then  there 
appears  thinning  of  the  choroid  with  irregular  deposit  of 
the  pigment  and  atrophy  of  the  choroidal  stroma,  so  that 
the  sclera  shows  through  in  the  form  of  a  crescent  at  the 
temporal  side  of  the  disk.  Such  a  myopic  crescent  is 


MYOPIA. 


161 


shown  in  Figs.  33  and  34  at  different  stages  in  its  develop- 
ment. Exactly  similar  appearances  brought  about  in  the 
same  way  may  be  seen  in  hyperopic  eyes.  But  as  the  eye 
passes  over  into  myopia,  the  choroidal  changes  generally 
continue.  A  crescentic  portion  of  the  choroid  adjoining 
the  atrophic  crescent  becomes  disturbed,  infiltrated,  and 
atrophied,  and  by  this  process  the  myopic  crescent  extends. 
Fig.  34  shows  the  extension  of  choroidal  changes  beyond 
the  original  crescent. 

The  distention  of  the  eyeball  continuing,  the  atrophic 
area  extends,  so  that  it  assumes  rather  a  triangular  form 
with  the  base  toward  the  disk  and  the  apex  toward  the 


FIG.  63.— Fundus  of  highly  myopiceye  with  "dragged"  disk,  large  "coniu." 
general  atrophy  of  retinal  pigment,  revealing  the  choroidal  vessels,  and 
patches  of  choroidal  atrophy,  one  of  which  is  commencing  in  the  macula. 


macula.     Such  an  area  is  called  a  conus.     At  the  same 
time    areas   of  thinned    and    disturbed    choroid    become 
noticeable  in  other  parts  of  the  fundus,  especially  near  the 
n 


162  SYMPTOMS. 

macula,  and  tend  to  undergo  atrophy.  These  appearances 
of  advanced  choroidal  change  are  illustrated  by  Fig.  63. 

The  degeneration  of  the  choroid  is  usually  attended 
with  vitreous  opacities.  In  a  few  cases  the  crescent  of 
atrophy  is  situated  not  at  the  temporal,  hut  at  the  upper, 
lower,  or  even  nasal  margin  of  the  disk.  As  it  grows 
larger  it  tends  to  encircle  the  disk. 

A  decided  atrophy  at  the  temporal  side  of  the  disk 
usually  accompanies  the  marked  bulging  of  the  sclera 
that  sometimes  occurs  at  this  point,  called  posterior 
staphyloma.  In  this  case  the  disk,  being  tilted  so  as  to 
face  rather  laterally  into  the  eye  and  not  forward  toward 
the  pupil,  appears  foreshortened,  narrow  from  side  to  side, 
and  therefore  more  of  an  ellipse,  with  the  long  axis  verti- 
cal. The  stretching  also  causes  the  vessels  to  run  straight 
across  the  region  of  atrophy,  as  shown  in  Fig.  63,  giving 
the  appearance  known  as  the  "  dragged  disk." 

The  retina  in  the  irritative  stages  of  myopia  may  be 
swollen  and  hazy  with  increased  reflexes.  The  "  Weiss 
reflex  "  (p.  100)  at  the  temporal  side  of  the  disk  has  some 
significance  as  a  sign  of  swelling.  Later,  in  some  parts  the 
retina  may  atrophy  with  the  underlying  choroid,  although 
generally  it  does  not.  In  very  high  myopia  the  retina  is 
liable  to  detachment,  probably  from  retraction  of  parts  of 
the  disorganized  and  partly  cicatricial  vitreous. 

Diagnosis. — Imperfect  vision  from  any  cause,  induc- 
ing the  patient  to  hold  print  or  small  objects  close  to  the 
eyes,  is  liable  to  be  called  near-sightedness.  But  in 
myopia  near  vision  is  always  relatively  better  than  dis- 
tant. A  hyperope  may  be  able  to  read  print  at  5  inches 
that  he  cannot  read  at  20  inches,  but  type  four  times  as 
large  will  be  read  more  easily  at  20  inches.  But  the 
myope  able  to  read  10-inch  type  at  5  inches  will  not  be 
able  to  read  40-inoh  type  at  20  inches. 

We  have  then  in  myopia  impaired  distant  vision,  which 
is  improved  by  the  pinhole  disk.  Near  vision  is  rela- 
tively good,  and  the  near-point  closer  to  the  eye  than  for 
the  emmetropie  eye  at  the  same  age.  With  the  ophthal- 
moscope the  fund  us  cannot  be  seen  clearly  in  the  erect 


MYOPIA.  ]  63 

image,  without  the  use  of  a  concave  lens ;  but  on  draw- 
ing back  from  the  eye  one  may,  in  very  high  myopia,  see 
clearly  an  inverted  image  of  the  fund  us.  By  skiascopy 
(p.  134)  a  point  of  reversal  is  found  between  the  surgeon  and 
the  patient's  eye,  or  closer  to  the  patient's  eye  than  the 
principal  focus  of  a  convex  lens  placed  in  front  of  it. 

Concave  lenses  render  clearer  the  distant  vision.  Under 
a  cycloplegic  the  lens  which  gives  the  best  distant  vision 
corrects  the  myopia.  When  the  eyes  are  not  free  from 
accommodation,  the  weakest  concave  lens  that  will  give 
the  patient  his  best  vision  is  to  be  sought,  by  trying  first 
lenses  that  are  too  weak,  and  as  their  strength  is  in- 
creased, noting  the  one  with  which  vision  ceases  to 
improve.  An  approximate  estimate  of  the  myopia  may 
be  made  by  measuring  the  greatest  distance  at  which  the 
finest  type  is  visible.  This  will  be  approximately  the 
distance  of  the  far-point  from  the  eye,  the  focal  distance 
of  the  lens  correcting  the  myopia. 

Treatment. — The  first  remedy  for  myopia  is  the 
wearing  of  correcting  lenses.  These  are  necessary  to 
remove  the  most  important  influences  that  tend  to  increase 
the  myopia,  and  to  give  the  patient  the  best  vision  of  which 
his  eyes  are  capable.  In  general,  they  should  correct  all 
the  myopia  and  should  be  worn  constantly.  The  excep- 
tions to  this  will  be  noted  presently.  Such  lenses  allow 
the  patient's  eye  to  work  under  conditions  most  nearly 
similar  to  those  of  emmetropia.  They  induce  him  to 
relax  his  accommodation  entirely  when  looking  at  distant 
objects — a  thing  he  may  not  do  when  it  will  not  bring 
clear  vision — and  to  use  the  normal  accommodation  for 
near-seeing.  They  discourage  excessive  convergence, 
since  with  it  must  occur  strain  of  accommodation.  They 
enable  the  patient  to  enter  upon  occupations  and  amuse- 
ments requiring  distant  vision,  and  to  escape  from  those 
which  tend  most  strongly  to  increase  his  myopia. 

Glasses  worn  only  a  part  of  the  time,  or  which  only 
partly  correct  the  myopia,  do  not  give  these  benefits. 
Lenses  partly  correcting  myopia  may  be  extremely  dan- 
gerous. For  rays  passing  through  it  obliquely  a  lens  acts 


164  TREATMENT. 

as  a  stronger  lens,  and  produces  a  greater  refractive  effect 
than  for  rays  passing  in  the  direction  of  its  primary  axis, 
perpendicular  to  its  surfaces.  The  myope  with  a  partial 
correction  finds  this  out,  finds  he  can  see  better  or  farther 
by  looking  obliquely  through  his  glasses,  and  does  so. 
But,  besides  increased  strength,  obliquity  gives  a  totally 
different  and  very  undesirable  effect.  It  causes  a  spherical 
lens  to  act  as  a  sphero-cylindrical  lens  or  a  sphero-cylin- 
drical to  act  like  one  having  a  cylinder  of  different 
strength  or  differently  placed.  This  exposes  the  patient 
to  the  dangers  of  eye-strain  from  astigmatism,  and  an 
astigmatism  that  varies  with  the  direction  in  which  the 
patient  looks. 

The  exceptions  to  the  constant  wearing  of  the  full  cor- 
rection are :  In  presbyopia,  glasses  which  allow  for  the 
failure  of  the  accommodation  must  be  given  for  near 
work.  They  are  determined  by  subtracting  from  the 
correcting  lenses  worn  for  far-seeing,  the  strength  required 
for  correcting  the  presbyopia  which  is  found,  either  by 
taking  the  near-point  with  the  correcting  glasses  on,  or  by 
taking  the  near-point  without  glasses,  and  from  it  and  the 
far-point  calculating  what  will  be  necessary  to  enable  the 
patient  to  do  his  near  work  without  using  more  than  two- 
thirds  of  his  accommodation. 

A  few  persons  who  have  not  reached  the  age  of  pres- 
byopia suffer  from  continued  use  of  even  less  than  half 
their  accommodation.  Such  persons,  if  emmetropic,  use 
convex  lenses  for  near  work,  and  if  myopic,  should  have 
glasses  weaker  than  their  correcting  lenses,  to  use  for  near 
work  only.  The  persons  who  are  better  off  for  a  permanent- 
arrangement  of  this  kind  are  but  few.  A  larger  number 
will  be  helped  by  wearing  weaker  concave  lenses  for  near 
work,  and  their  correcting  lenses  for  distance,  temporarily, 
while  becoming  fully  accustomed  to  the  latter. 

Patients  who  have  given  up  or  are  just  giving  up 
binocular  vision  should  not  always  be  given  correcting 
lenses.  In  some  cases  such  lenses  may  restore  binocular 
vision,  with  advantage  to  the  patient.  In  other  cases 
they  will  lead  to  persistence  in  the  attempt  to  use  both 


MYOPIA.  165 

eyes  together,  and  thus  to  further  increase  of  an  already 
high  myopia,  which  would  otherwise  be  checked  by  giv- 
ing up  binocular  vision  and  the  accompanying  effort  of 
convergence. 

Persons  who  see  very  imperfectly  through  their  correct- 
ing lenses  may  be  distinctly  worse  off  with  them,  because 
of  the  diminished  size  of  the  retinal  images.  The  retinal 
image  of  the  myopic  eye  is  larger  than  that  of  the  em- 
metropic  eye,  because  the  retina  is  farther  from  the  nodal 
point,  but  when  a  concave  lens  is  placed  before  the  eye 
the  nodal  point  is  shifted  back  toward  the  retina.  With 
the  correcting  lens  at  the  anterior  focus  of  the  eye,  about 
|-  inch  in  front  of  the  cornea,  the  retinal  images  are  the 
same  size  as  those  of  the  emmetropic  eye.  But  this  may 
be  such  a  reduction  in  their  size  as  to  cause  great  annoy- 
ance to  the  myope  accustomed  to  the  larger  images.  Such 
a  patient  may  go  without  glasses,  or  with  a  partial  cor- 
rection, since  he  will  feel  no  temptation  to  increase  the 
effect  of  the  lens  by  looking  through  it  obliquely. 

Operative  Treatment.  —  Persons  with  very  high 
myopia  experience  much  annoyance  from  the  strength  of 
their  correcting  lenses,  their  weight,  the  prismatic  effect 
if  they  get  slightly  out  of  place,  the  difficulty  in  becom- 
ing accustomed  to  them,  and  the  diminished  size  of  the 
retinal  images.  When  the  myopia  amounts  to  15.  D.  or 
over,  and  correcting  lenses  are  not  worn  with  satisfaction, 
or  perhaps  when  the  myopia  has  reached  13.  D.  before 
the  age  of  puberty,  and  is  still  rapidly  increasing,  in 
spite  of  correcting  lenses  and  abstinence  from  near  work, 
it  is  proper  to  practise  removal  of  the  clear  crystalline  lens. 
This  is  accomplished  in  children  by  needling  alone,  and 
in  adults  by  needling  the  lens  to  cause  a  traumatic  cata- 
ract, and,  before  it  causes  undue  swelling  of  the  lens  and 
irritation  of  the  eye,  extracting  it  like  any  other  soft 
cataract. 

The  removal  of  the  crystalline  lens  gives  much  larger 
retinal  images  than  the  wearing  of  a  correcting  lens, 
sometimes  more  than  50  per  cent,  larger,  and  if  every- 
thing goes  well,  it  may  be  expected  to  improve  the  acute- 


16G  OPERATIVE  TREATMENT. 

ness  of  vision  to  that  extent.  It  deprives  the  eye  of  the 
power  of  accommodation ;  but  to  the  eye  that  is  very 
highly  myopic  and  cannot  wear  a  correcting  lens,  accom- 
modation is  useless.  The  removal  of  the  clear  lens  is 
attended  with  about  the  same  risks  as  cataract  extraction, 
and  in  some  cases  confers  almost  equal  benefit.  It  does 
not,  however,  remove  the  danger  of  detachment  of  the 
retina,  and  sometimes  does  not  prevent  a  further  increase 
of  the  myopia.  It  should  not  be  done  unless  it  has  been 
demonstrated  with  lenses  that  correction  of  the  myopia 
can  greatly  improve  vision,  and  that  such  lenses  cannot 
be  comfortably  worn.  The  amount  of  myopia  corrected 
by  the  removal  of  the  crystalline  lens  varies  from  15.  D. 
to  30.  D.  The  higher  the  myopia,  the  greater  the  effect 
that  can  be  expected  from  the  operation.  Generally  the 
eye  after  operation  will  require  correcting  lenses  for  dis- 
tant vision  and  others  for  near  work. 

Besides  its  optical  treatment,  myopia,  if  at  all  progres- 
sive, demands  rest  from  near  work,  or  its  careful  regula- 
tion. Rest  will  sometimes  need  to  be  made  absolute  by 
the  continued  use  of  a  cycloplegic.  Regulation  includes 
care  of  the  conditions  under  which  eye-work  is  done, 
especially  avoidance  of  excessive  convergence,  and  limit- 
ing the  amount  within  the  endurance  of  the  eyes.  After 
acute  disease  care  must  be  taken  to  avoid  eye-work  until 
the  strength  has  been  fully  restored  ;  and  any  condition 
unfavorable  to  the  health  and  nutrition  of  the  coats  of  the 
eye  should  receive  attention. 

Prognosis.— Under  the  treatment  outlined  nearly  all 
cases  of  myopia  will  cease  to  be  progressive.  But  even 
if  the  eye  does  not  become  more  myopic,  if  it  be  already 
highly  so  in  early  life,  there  is  danger  of  degenerative 
changes  in  the  ocular  tissues  as  the  patient  groAvs  old.  If 
the  myopia  be  moderate  or  low,  there  is  a  probability  that 
it  will  slightly  decrease  as  the  patient  grows  older, 
through  continued  growth  of  the  crystalline  lens.  With 
correcting  lenses  even  high  degrees  of  M.  may  become 
quite  stationary.  The  writer  lias  seen  a  case  in  which 
20.  D.  lenses  fitted  at  the  age  of  nineteen  still  fully  cor- 


MYOPIA. 


167 


rected  the  myopia  thirty  years  later,  although  the  patient, 
a  clergyman,  had  used  the  eyes  to  excess  in  reading  and 
study. 

ASTIGMATISM  AND  CYLINDRICAL  LENSES. 

In  speaking  of  lenses  and  the  eye,  it  has  been  thus  far 
supposed  that  their  dioptric  surfaces  curved  equally  in  all 
directions,  and  that  the  light  coming  from  one  point  was 
perfectly  focussed  to  another  point.  To  an  eye  with  such 
surfaces  a  point  of  light,  such  as  a  star  or  distant  electric 
light,  appears  as  a  simple  point.  Most  persons,  however, 
see  such  a  point  of  light  either  as  a  line,  or  as  a  number 
of  lines  of  light  radiating  from  a  center,  the  conventional 
figure  of  a  star  *.  This  is  due  to  inequalities  in  the 
curves  of  the  dioptric  surfaces  of  the  eye,  which  prevent 
light  from  a  point  outside  the  eye  from  being  focussed 
perfectly  to  a  point  on  the  retina.  Hence  this  defect  is 
called  astigmatism  or  astigmia.  Astigmatism  is  divided 
into  regular  astigmatism  and  irregular.  When  the  word 
astigmatism  is  used  without  qualification,  regular  astigma- 
tism is  meant.  It  is  regular  astigmatism  that  we  are 
now  to  consider. 

A  cylindrical  lens,  or  a  "  cylinder,"  represents  the 
simplest  case  of  such  asymmetry  of  a  dioptric  surface. 
It  is  bounded  on  one  side  by  a  portion  of  the  surface  of  a 
cylinder.  Such  lenses  and  the  way  they  refract  light  are 
represented  in  Fig.  64,  which  represents  the  convex  cylin- 
drical lens,  and  Fig.  65,  which  represents  the  concave.  In 


FIG.  64.—  Refraction  by  a  convex  cylindrical  lens,  bringing  parallel  rays  to  a 

focal  line. 


one  direction  the  lens-surface  has  a  curve  like  that  which 
a  spherical  surface  has   in  all   directions,  but    at    right 


168 


A   CYLINDRICAL  LENS. 


angles  to  this  curve  the  surface  is  perfectly  straight.  A 
straight  line  AA  running  at  the  thickest  part  of  a  convex, 
or  the  thinnest  part  of  a  concave  lens,  is  called  the  axis 
of  the  lens. 

In  the  direction  of  its  axis  a  cylindrical  lens  has  no 
more  effect  on  the  light  passing  through  it  than  a  plate 


FIG.  65.— Refraction  by  a  concave  cylindrical  lens,  dispersing  rays  as  though 
from  a  focal  line. 


of  glass  with  parallel  sides.  In  the  direction  of  its  curve 
a  cylindrical  lens  focusses  light  like  a  spherical  lens  of 
the  same  strength.  If  we  consider  the  action  of  the  lens 
on  the  light  passing  through  it  in  a  plane  perpendicular 
to  the  axis,  we  see  that  the  light  will  continue  in  this 
plane,  being  turned  neither  up  nor  down,  and  that  the 
ray  passing  through  A  will  not  be  refracted  at  all,  but 
that  all  the  rays  passing  on  the  right  or  left  will  be 
turned  in  to  meet  this  central  ray  at  f\  The  same  thing 
happens  in  all  planes  perpendicular  to  the  axis,  so  that 
all  the  light  passing  through  the  lens  is  focussed  in  the 
points  of  the  line  FFt  which  may  be  called  the  focus  of 
the  cylindrical  lens. 

Since  a  cylindrical  lens  refracts  light  only  in  one  plane, 
in  prescribing  or  speaking  of  such  a  lens  it  is  necessary 
to  indicate  the  direction  of  its  axis  on  a  graduated  circle 
such  as  is  placed  on  the  front  of  trial  frames.  On  the 
scale  commonly  used  in  this  country  the  graduation  starts 
with  zero  at  the  right  of  the  horizontal  diameter  when 
the  circle  is  looked  at  from  in  front,  goes  upward  to  90°, 
which  is  vertical,  and  over  to  180°  at  the  left  of  the  hor- 
izontal diameter.  Or  the  graduation,  starting  at  the  left 


ASTIGMATISM  AND  CYLINDRICAL  LENSES.      169 

of  the  horizontal  diameter,  goes  downward  and  then  to 
the  right. 

The  regular  astigmatism  of  the  eye  is  due  chiefly 
to  the  shape  of  the  cornea,  and  it  often  is  convenient  to 
speak  as  if  it  were  wholly  due  to  the  cornea.  The  cornea 
curves  in  all  directions,  but  astigmatism  is  caused  by  its 
curving  more  in  one  direction  than  in  another.  The 
direction  in  which  it  curves  most  and  the  direction  in 
which  it  curves  least  are  (for  regular  astigmatism)  at 
right  angles  to  each  other.  They  are  called  the  principal 
meridians  of  corneal  curvature  or  the  principal  meridians 
of  astigmatism.  The  meridian  of  greatest  curvature  is 
commonly  vertical  or  nearly  so,  the  meridian  of  least 
curvature  horizontal  or  nearly  so.  When  this  is  the  case, 
it  is  said  to  be  astigmatism  according  to  the  rule;  when 
the  relative  curvatures  are  reversed,  it  is  astigmatism 
against  the  rule. 

The  refraction  of  light  by  an  astigmatic  eye  can  be 
best  understood  by  combining  a  spherical  +  10.  D.  with 


FIG.  66. — Refraction  of  light  in  principal  meridians  of  an  astigmatic  eye,  the 
upper  part  representing  the  vertical,  and  the  lower  part  the  horizontal  meri- 
dian. 

a  cylindrical  +  4.  D.  lens  from  the  trial  case  (or  by  using 
a  spherocylindrical  lens,  one  surface  spherical,  the  other 
surface  cylindrical,  of  this  strength),  and  studying  how 
it  focusses  light  from  a  distant  point  in  a  dark  room.  A 


170  ASTIGMATIC  REFRACTION. 

card  held  so  as  to  intercept  the  pencil  of  refracted  rays, 
first  at  one  and  then  at  another  distance  from  the  lens, 
shows  the  different  forms  the  pencil  assumes ;  and 
shutting  oif  part  of  the  surface  of  the  lens  with  colored 
glass  shows  what  part  of  the  pencil  the  rays  coming 
through  that  part  of  the  lens  occupy. 

The  focussing  of  light  by  the  astigmatic  eye  is  also 
illustrated  by  Fig.  66  in  which  FF  represents  the  meri- 
dian of  greatest,  and  HH  the  meridian  of  least  curvature. 
Vertically,  in  the  direction  of  FF,  all  the  rays  above  and 
below  are  turned  down  and  up  so  much  that  they  are 
brought  to  the  level  of  the  central  ray  at  F.  But  hori- 
zontally, in  the  direction  of  HH,  they  are  not  turned  in 
so  much  by  the  weaker  curve,  and  do  not  come  into  line 
with  the  central  ray  until  they  reach  G.  The  rays  are 
converged  in  both  directions,  but  unequally,  so  that  at  F, 
being  all  gathered  to  the  same  level  but  still  spread  out 
laterally,  they  form  a  horizontal  focal  line  FF.  Then 
they  begin  to  spread  out  up  and  down,  although  still 
gathering  together  from  the  sides,  until  at  G  they  are 
collected  in  the  vertical  focal  line  GG.  Beyond  G  they 
spread  out  in  all  directions.  FF  is  called  the  anterior 
focal  line,  and  GG  the  posterior  focal  line.  The  distance 
between  the  focal  lines  is  the  focal  interval  of  Sturm. 

The  greater  the  difference  between  the  curvatures  of 
FFand  HH,  the  greater  will  be  the  focal  interval,  the 
longer  the  focal  lines,  and  the  higher  the  degree  of  astig- 
matism. The  degree  of  astigmatism  is  expressed  by  the 
difference  in  the  refractive  power  of  the  eye  in  the  two 
principal  meridians.  It  is  corrected  by  the  cylindrical 
lens,  which  brings  the  two  focal  lines  together,  making 
them  a  single  point.  It  may  be  a  convex  cylinder,  placed 
so  that  its  curve  will  help  the  weaker  curve  of  the  cornea, 
which  will  bring  the  posterior  focal  line  forward  to  the 
anterior;  or  it  may  be  a  concave  cylinder  placed  so  that 
its  curve  will  partly  neutralize  the  stronger  curve  of  the 
cornea,  and  thus  carry  the  anterior  back  to  the  posterior 
focal  line.  It  will  be  noticed  that  the  horizontal  focal 
line  has  its  position  fixed  by  the  vertical  curve  of  the 


ASTIGMATISM  AND  CYLINDRICAL  LENSES.      171 

cornea,  and  that  the  vertical  focal  line  has  its  position 
fixed  by  the  horizontal  curve  of  the  cornea.  To  help  the 
horizontal  curve  of  the  cornea  the  curve  of  the  lens  must 
be  horizontal  and  its  axis  vertical,  and  to  neutralize  the 
vertical  curve  the  curve  of  the  lens  must  be  vertical  and 
its  axis  horizontal.  The  curve  of  the  lens  being  applied 
to  a  certain  curve  of  the  eye,  the  axis  of  the  lens  at  right 
angles  to  that  curve  has  the  direction  of  the  focal  line 
which  the  lens  affects. 

Appearance  of  Lines. — Astigmatism  affects  the  seeing 
of  lines  in  this  way.  One  of  the  focal  lines  is  the  nearest 
to  a  focus  that  rays  are  brought  by  the  astigmatic  eye — 
the  anterior  focal  line  being  a  little  the  shorter  of  the 
two.  When  one  of  these  focal  lines  is  brought  on  the 
retina,  as  it  usually  can  be  by  the  accommodation,  lines 
looked  at  which  run  in  the  same  direction  as  the  focal 
line  will  be  seen  clearly,  but  all  other  lines  will  be 
blurred.  Each  point  of  a  line  makes  the  impression  of 
a  focal  line  on  the  retina.  If  these  impressions  overlap, 
they  reinforce  each  other,  and  make  the  strong  distinct 
impression  of  a  single  line.  But  if  these  impressions, 
instead  of  overlapping  each  other,  overlap  the  impressions 
made  by  other  points  at  the  sides  of  the  lines,  they  are 
weakened  so  as  to  cause  a  blur. 

This  is  illustrated  in  Fig.  67,  in  which  A  shows  parallel 


FIG.  67.— Appearance  of  lines  running  in  different  directions:  A,  as  seen  by 
the  normal  eye  ;  /},  as  seen  by  the  astigmatic  eye, 

lines  as  they  appear  to  the  eye  free  from  astigmatism, 
each  point  of  the  line  making  its  impression  on  a  single 
point  of  the  retina,  and  not  overlapping  in  any  direction. 


172  APPEARANCE  OF  LINES. 

B  represents  the  appearance  these  lines  present  to  an  astig- 
matic eye  with  the  vertical  focal  line  falling  on  the 
retina,  each  point  making  the  impression  of  a  vertical 
line.  For  the  vertical  lines  the  impressions  overlapping 
one  another  make  the  lines  sharp  except  at  the  ends,  which 
are  blurred.  But  for  the  horizontal  line  the  vertical  over- 
lapping runs  them  together,  making  a  broad  blurred  band 
with  distinct  ends. 

Causes  and  Seat. — Astigmatism  is  commonly  due  to 
a  congenital  anomalous  development  of  the  cornea.  Some- 
times the  asymmetry  of  the  corneal  curvature  develops 
during  childhood  or  in  adult  life.  It  may  be  produced 
by  extensive  corneal  wounds,  as  that  made  for  cataract- 
extraction,  in  which  case  the  cornea  is  flattened  in  the 
meridian  perpendicular  to  the  corneal  incision.  It  may 
be  produced  by  cicatricial  changes  following  corneal 
ulcers,  or  by  the  bulging  of  the  conical  cornea.  In  most 
eyes  the  difference  between  the  corneal  astigmatism  as 
measured  by  the  ophthalmometer,  and  the  total  or  net 
astigmatism  of  the  eye  as  measured  by  skiascopy  or  the 
test  lenses,  shows  that  the  crystalline  lens  also  takes  part 
in  the  causation  of  astigmatism.  Usually  the  lens-astig- 
matism partly  neutralizes  that  of  the  cornea,  the  net 
astigmatism  of  the  eye  being  less  than  that  of  the  cornea 
alone,  yet  in  some  eyes  the  lens-astigmatism  greatly  pre- 
dominates. Lens-astigmatism  may  be  due  to  asymmetry 
of  the  lens-surfaces,  or  to  their  being  placed  obliquely 
with  regard  to  the  rays  entering  the  pupil. 

Varieties. — Astigmatism  is  always  ametropia  of 
curvature,  its  direction  and  amount  being  entirely  inde- 
pendent of  the  position  of  the  retina.  Still  its  recognized 
clinical  varieties  are  based  on  the  various  positions  of  the 
retina  with  reference  to  its  focal  lines.  These  are  five  in 
number.  They  are  illustrated  in  Fig.  68,  in  which  F 
represents  the  anterior  and  G  the  posterior  focal  line. 
The  retina  may  be  in  front  of  both  focal  lines  as  at  (1) 
the  eye  hyperopic  in  both  principal  meridians ;  this  is 
called  compound  hyperopic  astigmatism.  The  retina  may 
pass  through  the  anterior  focal  line  (2),  the  eye  being 


ASTIGMATISM  AND  CYLINDRICAL   LENSES.      173 

hyperopic  for  the  meridian  of  least  curvature  and  emme- 
tropic  for  the  other ;  this  is  simple  hyperopic  astigmatism. 
The  retina  may  lie  between  the  focal  lines  (3),  the  eye 
being  still  hyperopic  for  the  meridian  of  least  curvature, 
but  myopic  for  the  meridian  of  greatest  curvature — mixed 


)1 


FIG.  68.— Different  positions  of  the  retina  with  reference  to  the  focal  lines: 
1,  compound  hyperopic ;  2,  simple  hyperopic;  3,  mixed  astigmatism ;  4,  simple 
myopic ;  5,  compound  myopic. 

astigmatism.  The  retina  may  pass  through  the  posterior 
focal  line  (4),  the  eye  being  myopic  for  the  meridian  of 
greatest  curvature  and  emmetropic  for  the  meridian  of 
least  curvature — simple  myopic  astigmatism.  The  retina 
may  lie  beyond  the  posterior  focal  line  (5),  making  the 
eye  myopic  for  both  meridians — compound  myopic  astig- 
matism. 

By  elongation  of  the  eyeball,  such  as  produces  myopia, 
the  same  eye  may  pass  from  compound  hyperopic  to  com- 
pound myopic  astigmatism  through  all  the  intermediate 
varieties,  without  material  change  in  the  direction  or 
curvature  of  the  principal  meridians,  and  without  change 
in  the  amount  of  the  astigmatism. 

Symptoms. — Astigmatism  of  high  degree  always 
diminishes  actiteness  of  vision,  both  distant  and  near. 
The  extent  to  which  it  does  this  depends  on  the  degree 
of  the  astigmatism,  the  size  of  the  pupil,  and  the  ability 
of  the  patient  to  piece  together  and  interpret  partial 
retinal  images ;  for  the  astigmatic  eye  can  often  by  a  cer- 
tain amount  of  accommodation  bring  one  focal  line  on  the 
retina,  so  that  certain  lines  are  seen  clearly,  and  then  by 
another  amount  of  accommodation  it  can  bring  the  other 
focal  line  on  the  retina,  and  see  other  lines  clearly.  The 
mental  ability  to  combine  and  utilize  the  partial  impres- 


174  SYMPTOMS. 

sions  so  obtained  will  greatly  influence  the  patient's 
response  to  the  ordinary  tests  of  visual  acuteness. 

Normal  acuteness  of  vision  by  the  usual  standard  may 
be  possessed  by  eyes  so  astigmatic  as  to  cause  serious 
eye-strain.  It  is  by  eye-strain  that  low  degrees  of  astig- 
matism manifest  their  existence.  The  symptoms  depend 
on  the  requirements  made  of  the  eyes  in  the  way  of  close 
work,  and  the  endurance  of  the  nervous  system  and 
ocular  tissues,  as  determined  by  the  state  of  the  general 
health. 

The  liability  to  headache,  its  character,  and  amenability 
to  other  treatment  are  much  the  same  with  astigmatism 
as  with  other  forms  of  ametropia.  Astigmatism  causes 
the  same  congestion,  or  chronic  or  recurring  inflammation 
of  the  conjunctiva  and  lid-margins.  It  is  a  very  impor- 
tant cause  of  the  choroidal  changes  that  accompany  and 
probably  aid  in  causing  myopia.  Many  cases  pass,  as 
Risley  says,  from  hyperopia  to  myopia  "  through  the  turn- 
stile of  astigmatism."  The  symptoms  of  astigmatism 
may  vary  with  the  amount  of  effort  required  of  the  eyes, 
or  they  may  be  more  apparently  connected  with  varia- 
tions in  the  general  health. 

Diagnosis. — Impairment  of  vision  is  always  present 
with  astigmatism  of  high  degree,  but  it  is  less  than  for 
the  same  degree  of  hyperopia  or  myopia.  It  affects  dis- 
tant and  near  vision  about  equally.  The  patient  usually 
recognizes  some  letters  better  than  others,  miscalling 
some  letters  in  one  line,  and  reading  others  correctly  that 
are  two  or  three  lines  smaller.  The  near-point  is  about 
where  it  would  be  for  emmetropia  at  the  patient's  age, 
unless  there  is  also  hyperopia  or  myopia  to  affect  it.  With 
the  special  test-cards  of  radiating  lines,  the  lines  running 
in  some  one  direction  (usually  the  direction  of  the  pos- 
terior focal  line  if  accommodation  is  good)  are  seen  more 
clearly  than  others ;  but  sometimes  a  patient  will  deny 
that  the  lines  are  clearer  in  any  one  direction,  or  will  give 
contradictory  answers. 

On  looking  at  a  ]>o!nt  of  //(/fit  the  astigmatic  eye  may 
see  it  as  a  line  of  light,  the  lens  indicating  the  direction 


ASTIGMATISM  AND  CYLINDRICAL  LENSES.      175 

of  one  of  the  principal  meridians.  This  is  made  the 
basis  of  certain  tests  for  astigmatism,  but  if  the  pupil  is 
dilated,  the  line  significant  of  regular  astigmatism  is  in 
many  eyes  masked  by  the  radiating  lines  due  to  irregular 
astigmatism.  Hotz's  astigmometer  and  Thomson's  ame- 
trometer  are  based  on  this  distortion  of  a  point  of  light 
as  seen  with  an  astigmatic  eye. 

In  the  trial  case  will  be  found  a  metal  disk  with  a  nar- 
row slit  in  it,  the  stenopaic  slit.  If  this  be  placed  before 
an  astigmatic  eye  and  turned  in  various  directions,  it  is 
found  that  a  certain  direction  gives  the  best  vision,  and 
that  at  right  angles  to  this  the  vision  is  worst.  The 
former  direction  is  that  of  the  least  ametropic  curve; 
the  latter  direction  is  that  of  the  most  ametropic  curve. 
The  slit  being  placed  in  one  of  these  directions,  the 
spherical  lens  which  most  improves  the  vision  is  the  lens 
which  corrects  that  principal  meridian.  When  both 


FIG.  69.— KadwtiiiK  lines  test  for  astigmatism. 

meridians  have  thus  been  tested,  the  difference  between 
the  two  is  the  amount  of  astigmatism. 

Difference  in  the  distinctness  of  lines  running  in  differ- 
ent   directions   may   be  detected   by   looking  at  such    a 


176  DIAGNOSIS  OF  ASTIGMATISM. 

figure  as  is  shown  in  Fig.  69.  If  difference  of  clearness 
in  the  radiating  lines  is  noticed,  three  parallel  lines,  small 
enough  to  be  just  distinguishable  at  the  distance  at  which 
they  are  placed,  may  be  turned  in  different  directions, 
and  that  direction  noted  in  which  they  appear  clearest. 
By  trial  the  spherical  lens  is  then  found  which  renders 
the  lines  most  distinct  in  that  direction.  It  is  the  meas- 
ure of  the  ametropia  in  the  meridian  at  right  angles  to 
the  lines.  The  lines  are  then  turned  90  degrees,  and  the 
lens  found  which  renders  them  most  clear  in  that  direc- 
tion. The  difference  between  the  two  lenses  measures 
the  astigmatism. 

If  either  of  the  above  tests  are  applied  to  an  eye 
which  has  power  of  accommodation,  the  strongest  convex 
or  weakest  concave  lens  which  fulfils  the  necessary  con- 
ditions is  the  one  to  be'  aimed  at.  Thus,  the  strongest 
convex  or  weakest  concave  lens  that  leaves  the  line  of 
light  will  fix  its  direction  most  definitely  with  the  Hotz 
or  Thomson  instruments.  The  strongest  convex  or  weak- 
est concave  lens  that  gives  the  best  vision  with  the 
stenopaic  slit,  or  renders  the  parallel  lines  most  distinct, 
is  the  one  which  most  nearly  indicates  the  ametropia  in 
the  corresponding  meridian. 

The  above  subjective  tests  are  of  value  for  discovering 
and  approximately  measuring  astigmatism.  The  objective 
methods  of  approximately  estimating  astigmatism  are,  by 
the  refraction  ophthalmoscope,  by  measuring  the  corueal 
astigmatism  with  the  ophthalmometer,  and  by  skiascopy. 

The  value  of  the  ophthalmoscope  in  the  diagnosis  of 
astigmatism  depends  on  the  fact  that  a  pencil  of  rays 
emerging  through  an  astigmatic  cornea  is  rendered  astig- 
matic, so  that  it  forms  on  the  retina  of  the  surgeon,  not  a 
point  but  a  focal  line.  Such  focal  lines  enable  the  sur- 
geon to  see  clearly  those  lines  in  the  patient's  retina  which 
run  parallel  to  them,  while  all  others  are  blurred.  Thus, 
if  a  vertical  focal  line  falls  on  the  surgeon's  retina,  he 
sees  clearly  the  parts  of  the  patient's  retinal  vessels  which 
run  vertically,  or  the  vertical  sides  of  the  patient's  optic 
disk ;  but  all  other  parts  of  the  retinal  vessels,  and  all 


ASTIGMATISM  AND  CYLINDRICAL  LENSES.      177 

other  parts  of  the  outline  of  the  optic  disk  appear  blurred, 
the  parts  that  run  horizontally  being  most  blurred.  The 
peculiar  appearance  of  the  fundus  in  a  highly  astigmatic 
eye  is  best  reproduced  by  looking  through  a  +  6.  D. 
cylindrical  lens  at  a  picture  of  the  normal  fundus  (Plate  I.) 
held  at  a  distance  of  10  or  12  inches. 

The  direction  in  which  the  lines  appear  most  clear  is 
the  direction  of  one  of  the  principal  meridians  of  astigma- 
tism. It  is  most  accurately  determined  with  the  strongest 


FIG.  70.— Javal-Schiotz  ophthalmometer. 


convex  or  weakest  concave  lens  that  leaves  the  vessels 
clear  in  any  one  direction  ;  that  lens  also  measures  the 
ametropia  in  that  meridian.  The  other  principal  meri- 
dian is  at  right  angles  to  the  first,  and  the  strongest 
convex  or  weakest  concave  lens  that  renders  the  vessels 
clear  in  that  direction  measures  its  ametropia.  The 
difference  between  the  two  gives  the  astigmatism. 
12 


178  THE  OPHTHALMOMETER. 

The  ophthalmometer  measures  the  curvature  of  the 
cornea  by  the  size  of  the  reflection  it  gives  of  a  known 
object.  The  instrument  of  Javal  and  Schiotz  has  had 
most  general  clinical  use.  It  is  illustrated  in  Fig.  70 
and  is  now  alone  alluded  to.  In  it  the  test-object  is  the 
distance  between  the  two  "mires"  MM  which  are  movable 
on  the  arm  A,  which  revolves  in  front  of  the  large  disk 
D.  This  object  is  placed  a  fixed  distance  from  the 
patient's  eye,  the  distance  at  which  the  telescope  BE, 
through  which  the  surgeon  looks,  focusses  the  reflection 
from  the  patient's  cornea,  so  that  both  it  and  the  cross- 
hairs fixed  in  the  body  of  the  telescope  are  seen  clearly. 
The  size  of  the  reflection  is  fixed  by  the  strength  of  a 
"  doubling  prism"  behind  the  object-glass  of  the  telescope, 
a  reflection  of  the  proper  size  being  secured  when  the  two 
adjoining  images  of  the  mires,  as  seen  through  the  tele- 
scope, appear  to  touch.  They  are  made  to  touch  by 
moving  one  of  the  mires ;  and  when  they  touch,  the  posi- 
tion of  an  index  on  the  mire  indicates  on  the  arm  the 
radius  of  curvature  of  the  cornea  in  millimeters,  and  the 
refraction  of  the  eye  in  that  meridian  in  diopters. 

To  use  the  instrument  the  disk  and  mires  must 
be  strongly  illuminated.  The  patient,  with  his  brow 
applied  to  the  head-rest  H  and  his  chin  on  C,  looks 
with  the  eye  to  be  measured  into  the  telescope,  the 
other  eye  being  covered.  The  surgeon,  looking  through 
the  telescope  from  E,  directs  it  so  that  the  adjoining 


A  P 

FIG.  71. — Mires  of  the  ophthalmometer :  A,  with  the  arm  not  corresponding 
to  either  principal  meridian  of  the  cornea  ;  B,  turned  to  one  of  the  principal 
meridians. 

images  of  the    two    mires   come    to    the    center  of  the 
field.     If  the  black  lines  across  the   two   mires  do  not 


ASTIGMATISM  AND  CYLINDRICAL  LENSES.      179 

appear  continuous  as  in  Fig.  71  A,  the  arm  is  not  parallel 
to  either  of  the  principal  meridians  of  the  cornea.  It 
must  first  be  made  parallel  to  one  of  these  meridians  and 
the  lines  continuous,  as  at  B,  by  revolving  the  body  of 
the  telescope.  When  the  arm  corresponds  to  one  of  the 
principal  meridians,  the  movable  mire  must  be  shifted 
till  its  reflection  just  touches  that  of  the  fixed  mire,  as  at 
C  in  Fig.  72.  The  arm  is  then  rotated  to  the  other 
principal  meridian.  If  the  mires  overlap  as  at  D,  Fig.  72, 


FIG.  72.— Mires  of  the  ophthalmometer :  C,  in  the  meridian  of  least  refrac- 
tion, just  touching;  D,  in  the  meridian  of  greatest  refraction,  overlapping  for 
1.75  D.  of  astigmatism. 

the  number  of  steps  of  overlapping  shows  the  number  of 
diopters  of  astigmatism.  If  the  mires  separate,  as  at  B 
in  Fig.  71,  the  movable  mire  must  be  shifted  until  it 
touches  the  other,  and  the  arm  then  rotated  back  to  the 
first  principal  meridian,  when  the  overlapping  will  indi- 
cate the  astigmatism.  The  overlapping  occurs  in  the 
meridian  of  greatest  curvature,  the  vertical  meridian  in 
astigmatism  with  the  rule. 

Reid's  ophthalmometer  is  a  practical  instrument,  and 
being  but  little  larger  than  an  ophthalmoscope  is  readily 
carried  and  used  anywhere.  In  it  the  test-object  is  a 
circular  opening  in  the  side  of  the  telescope,  the  size  of 
which  is  varied  by  an  iris  diaphragm.  The  reflection  of 
this  object  from  an  astigmatic  cornea  is  an  ellipse,  and 
the  sizes  of  the  opening  necessary  to  render  the  doubled 
images  of  the  ellipse  just  tangent,  first  in  the  direction  of 
the  long  axis,  and  then  in  the  direction  of  the  short  axis, 
indicate  the  ametropia  in  the  principal  meridians.  The 
difference  between  the  two  meridians  gives  the  astigma- 


180  THE  OPHTHALMOMETER. 

tism.  The  short  axis  of  the  ellipse  corresponds  to  the 
meridian  of  greater  curvature  of  the  cornea. 

In  a  great  many  eyes  the  corneal  astigmatism  is  about 
0.5  D.  greater  than  the  total  or  net  astigmatism  of  the 
eye.  This  amount  deducted  from  the  corneal  astigma- 
tism when  with  the  rule,  or  added  to  it  when  it  is  against 
the  rule,  may  be  taken  as  the  indication  of  the  ophthal- 
mometer.  But  it  must  always  be  remembered  that  the 
difference  between  the  corneal  and  the  net  astigmatism 
may  be  very  much  greater,  and  that  they  may  have  their 
principal  meridians  in  totally  different  directions. 

Skiascopy  is  by  far  the  best  objective  method  for 
measuring  astigmatism.  The  rays  emerging  from  the  astig- 
matic eye  when  made  to  converge  (by  a  convex  lens  when 
the  eye  is  not  myopic)  come  together,  not  at  a  single 
point  but  at  two  points  of  reversal,  one  for  each  principal 
meridian.  At  each  of  these  points  of  reversal  the  light 
in  the  pupil  assumes  more  or  less  the  appearance  of  a 
band,  running  in  the  direction  of  the  principal  meridian 
to  which  the  point  of  reversal  belongs.  This  band-like 
appearance  is  illustrated  in  Fig.  73.  It  is  brought  out 


•••••^•••MMMMHBMI 

FIG.  73. — Band-like  appearance  in  direction  of  principal  meridian  of  greatest 
curvature  at  70°. 


most  distinctly  when  the  source  of  light  is  a  small  circular 
opening  in  the  metal  shade  over  the  lamp-flame,  this 
source  being  so  placed  that  the  light  enters  the  patient's 
eye  as  if  from  the  point  of  reversal  of  the  other  principal 
meridian. 

The  movement  and  appearance  of  light  in  the  pupil 


ASTIGMATISM  AND  CYLINDRICAL  LENSES.      181 

from  different  distances  (with  the  plane  mirror)  are  as 
follows :  When  closer  to  the  patient's  eye  than  the  point 
of  reversal  the  surgeon  sees  the  light  moving  "  with  "  the 
light  on  the  face  in  all  directions.  As  he  draws  back, 
approaching  that  point  of  reversal  which  is  the  nearer  to 
the  patient,  the  light  is  seen  to  move  more  swiftly  in  the 
direction  of  the  meridian  to  which  that  point  of  reversal 
belongs,  and  to  assume  the  appearance  of  a  band  running 
in  that  direction.  At  the  nearer  point  of  reversal  it  can- 
not be  distinguished  which  way  the  light  moves  in  the 
direction  of  the  band,  but  at  right  angles  to  its  length 
the  band  is  readily  made  to  move  "  with  "  the  light  on 
the  face.  Withdrawing  still  farther  from  the  patient,  the 
movement  in  the  direction  of  the  band  is  again  distin- 
guished, but  it  is  now  "against"  the  light  on  the  face. 
The  movement  still  continues  "  with  "  the  light  on  the 
face  in  the  other  meridian.  The  band  now  rapidly 
becomes  indistinct,  and  half-way  between  the  two  points 
of  reversal  not  a  trace  of  it  remains.  Here  the  appearance 
of  light  in  the  pupil  is  precisely  the  same  as  in  an  eye  free 
from  astigmatism,  except  that  the  light  moves  "  with " 
the  light  on  the  face  in  one  meridian  and  "against"  it  in 
the  other.  Still  farther  from  the  patient's  eye  the  band 
begins  to  be  seen  in  the  direction  of  the  other  principal 
meridian,  and  the  movement  of  light  in  that  meridian, 
still  "  with  "  the  light  on  the  face,  becomes  more  rapid. 
At  the  point  of  reversal  for  the  meridian  of  least  curva- 
ture, the  band  is  seen  running  in  the  direction  of  that 
meridian.  The  movement  in  the  direction  of  this  band 
is  now  indistinguishable,  and  the  movement  in  the  other 
meridian  is  "against"  that  of  the  light  on  the  face. 
Withdrawing  beyond  this  farther  point  of  reversal  the 
movement  is  found  to  be  "against"  the  light  on  the  face 
in  all  directions,  rapid  at  first  in  the  direction  of  the  last 
band,  but  soon  growing  slower  in  all  directions. 

To  illustrate  the  use  of  skiaseopy,  let  us  suppose  an  eye 
requiring  a  correction  of  +  1.  sph.  O  +  1.  cyl.  ax.  90°,  to 
be  examined  with  the  plane  mirror.  The  surgeon  sits 
two  or  three  feet  in  front  of  the  patient  with  the  mirror 


182  SKIASCOPY. 

to  his  eye,  and  the  light  as  close  as  possible  to  the  mirror. 
Reflecting  the  light  on  the  patient's  eye  the  light  in  the 
pupil  is  found  to  move  "  with  "  the  light  on  the  face  in 
all  directions ;  and  because  the  light  in  the  pupil  moves 
rather  slowly,  it  is  known  that  considerable  lens-strength 
will  be  needed  to  bring  a  point  of  reversal  to  the  surgeon's 
eye. 

A  +  3.  D.  sph.  is  placed  before  the  eye.  With  this  the 
movement  is  "against"  the  light  on  the  face  up  and  down, 
but  still  "  with  "  it  from  side  to  side.  This  shows  astig- 
matism. The  surgeon  then  leans  toward  the  patient  and 
at  0.5  meter  (20  inches)  from  the  patient's  eye  the  verti- 
cal movement  "  against "  is  replaced  by  a  vertical  band, 
in  the  direction  of  which  the  movement  is  indistinguish- 
able. This  band  moves  from  side  to  side  "  with "  the 
mirror.  This,  then,  is  the  nearer  point  of  reversal.  To 
fix  most  accurately  its  direction,  while  keeping  the  observ- 
ing eye  at  20  inches  from  the  patient's,  the  light  is  pushed 
away  from  the  mirror  until,  when  it  is  20  inches  from  the 
mirror,  the  band  becomes  most  distinct,  the  light  now 
being  reflected  from  the  mirror  as  if  it  came  from  a  point 
40  inches  away — the  farther  point  of  reversal.  Under 
these  circumstances  the  band  from  1.  D.  of  astigmatism 
may  be  quite  as  distinct  as  that  shown  in  Fig.  73. 

Having  thus  determined  one  principal  meridian,  the 
other  (being  always  at  right  angles  to  it)  is  also  known. 
The  point  of  reversal  is  then  carefully  determined  by 
bringing  the  light  as  close  as  possible  to  the  mirror,  and 
getting  the  movement  in  the  vertical  meridian  alternately 
"  with  "  and  "  against,"  noting  where  it  changes  from  one 
to  the  other.  Its  distance  from  the  eye  is  then  measured, 
20  inches,  corresponding  to  2.  D.  of  myopia.  As  the 
3.  D.  lens  causes  2.  D.  of  M.,  there  must  have  been 
3  —  2  =  1.  D.  of  hyperopia  in  this  meridian.  The  other 
point  of  reversal  is  then  determined  in  the  same  way. 
In  this  case  it  is  found  to  be  at  40  inches  or  one  meter 
from  the  eye;  indicating  that  the  lens  used  causes  1.  D. 
of  myopia  in  this  meridian,  and  that  without  the  lens 
there  is  3  —  1  ~  2.  D.  of  hyperopia  in  the  meridian  of  least 


ASTIGMATISM  AND  CYLINDRICAL  LENSES.      183 

curvature.  The  difference  between  the  two  meridians,  or 
1.  D.,  is  the  amount  of  astigmatism. 

To  confirm  the  results  obtained  by  skiascopy  it  is 
always  best  to  place  before  the  eye  the  cylinder  that  is 
expected  to  correct  the  astigmatism,  and  repeat  the  test 
to  see  if  it  really  does  so.  Thus,  in  the  above  case, 
placing  a  + 1.  D.  cyl.  ax.  90°  before  the  eye,  the  point 
of  reversal  will  be  found  at  20  inches  for  all  meridians ; 
on  placing  a  —  1.  D.  cyl.  ax.  180°  before  the  eye,  the 
point  of  reversal  will  be  found  at  40  inches  for  all 
meridians. 

When  the  astigmatism  is  low  (0.5  D.  or  less),  it  may 
be  impossible  to  bring  out  a  band  of  light  in  the  pupil. 
But  it  can  be  noticed  that  the  movement  becomes  indis- 
tinguishable, or  reverses  sooner  in  one  direction  than  in 
others ;  and  this  proves  the  existence,  and  indicates  the 
meridians  of  the  astigmatism. 

The  test-lenses  have  been  called  the  court  of  last 
appeal  in  the  diagnosis  of  errors  of  refraction.  But  in 
this  connection  it  should  be  remembered  that  the  real 
value  of  the  decision  of  a  court  of  last  appeal  rests  on  its 
opportunity  to  review  all  the  arguments  and  decisions 
that  have  gone  before.  The  accuracy  of  the  result 
obtained  with  the  test-lenses  depends  largely  on  the 
knowledge  of  the  refraction  previously  acquired  by  skias- 
copy and  other  methods.  If  one  cannot  use  skiascopy 
and  has  no  ophthalmometer,  the  stenopaic  slit  or  the 
parallel  lines  with  spherical  lenses  can  give  very  valuable 
assistance  in  the  diagnosis  of  astigmatism. 

The  trial  with  the  test-lenses  should  begin  by  placing 
in  the  trial-frames,  before  the  eye,  the  correcting  lenses, 
as  these  have  been  determined  by  other  methods.  When 
the  patient  has  read  the  test-letters  as  far  as  he  can  with 
these,  they  are  to  be  modified  by  holding  in  front  of  them 
supplementary  lenses.  First  +  0.50  and  —0.50  spherical, 
may  be  alternated  unless  the  vision  is  still  quite  poor, 
when  +  1.  and  —  1.  D.  should  be  used.  If  either  of  these 
improves  vision,  a  corresponding  change  is  to  be  made  in 
the  lens  in  the  trial-frame ;  and  the  trial  with  supple- 


184  TRIAL-LENSES. 

mentary  lenses  repeated  until  any  change  in  the  spherical 
makes  vision  worse. 

Then  the  direction  of  the  cylinder  may  be  tested  by 
turning  it  first  to  the  right  then  to  the  left,  and  asking 
the  patient  to  say  "  stop,"  as  soon  as  the  change  begins  to 
make  vision  worse.  The  points  on  each  side,  at  which 
vision  is  rendered  perceptibly  worse,  must  be  carefully 
noted  in  repeated  trials,  and  a  point  half-way  between 
them  is  the  proper  direction  for  the  axis  of  the  cylinder. 

To  test  the  strength  of  the  cylinder  the  astigmatic  lens 
should  be  used.  This  is  a  crossed  cylinder,  or  an  equiva- 
lent sphero-cylindrical  lens,  convex  in  one  meridian  and 
equally  concave  in  the  meridian  at  right. angles  to  that. 
The  most  useful  combination  is  —  0.25  sph.  o  +  0.50 
cyl.,  but  a  lens  of  double  that  strength  and  one  of  half 
that  strength  are  also  useful.  The  astigmatic  lens  is  used  as 
a  supplementary  lens,  the  axis  of  the  cylinder  being  first 
held  in  the  same  direction  as  the  axis  of  the  cylinder  in 
the  trial-frame,  and  then  turned  perpendicular  to  it.  In 
one  position  it  adds  to  the  effect  of  the  cylinder  in  the 
trial-frame ;  in  the  other  it  diminishes  that  effect.  The 
patient  is  asked  which  way  is  the  better,  or  whether  one 
way  is  any  better  than  the  other.  If  it  makes  no  differ- 
ence which  way  the  astigmatic  lens  is  turned,  the  cylinder 
already  in  the  trial-frame  is  of  the  right  strength.  If 
the  astigmatic  lens  does  make  it  better  in  one  direction 
than  the  other,  the  cylinder  in  the  trial-frame  is  to  be 
changed  according  to  that  indication. 

After  this  the  strength  of  the  spherical  is  again  to  be 
tested,  in  connection  with  the  new  cylinder,  and  the  direc- 
tion of  its  axis  must  be  re-tested  ;  this  process  must  con- 
tinue until  any  change  in  the  lenses  makes  vision  worse. 
The  testing  should  be  interrupted  to  let  the  patient  rest 
whenever  he  becomes  tired,  otherwise  his  answers  become 
unreliable.  When  there  is  any  discrepancy  between  the 
results  of  skiascopy  and  the  test-lenses,  it  may  be  well  to 
repeat  skiascopy,  and,  after  the  eye  has  recovered  from 
mydriasis,  to  try  it  with  the  lenses  again. 

Treatment. — Astigmatism,   when   it   requires   treat- 


ASTIGMATISM  AND  CYLINDRICAL  LENSES.       185 

ment,  demands  the  constant  use  of  correcting  lenses.  Low 
degrees  do  not  materially  impair  the  acuteness  of  vision, 
and  if  the  eyes  are  not  used  much,  and  no  sign  of  eye- 
strain  arises,  nothing  need  be  done  for  it.  When,  how- 
ever, glasses  have  to  be  worn  for  hyperopia  or  myopia,  if 
any  astigmatism  is  present,  even  0.25  D.,  it  is  usually 
better  to  correct  it. 

Since  any  case  of  astigmatism  can  be  corrected  by 
either  a  convex  cylinder  with  its  curve  in  the  direction  of 
the  less  curved  meridian,  or  a  concave  cylinder  with  its 
curve  to  the  more  curved  meridian,  there  is  always  a 
chance  to  choose  between  two  combinations.  It  has  been 
customary  to  correct  hyperopic  astigmatism  with  a  convex, 
and  myopic  astigmatism  with  a  concave  cylinder,  thus : 

+  1.  sph.  o  +  l.  cyl.  ax.  90°. 
But 

+  2.  sph.  o-l.  cyl.  ax.  180° 

is  equally  effective.  It  will  be  noticed  that  the  first  re- 
quires the  use  of  a  weaker  spherical  than  the  second  ;  but 
the  second,  having  one  concave  and  one  convex  side,  if 
mounted  with  the  former  toward  the  eye,  gives  the  advan- 
tage of  a  periscopic  lens. 

Any  case  of  astigmatism  can  be  corrected  by  crossed 
cylinders,  as  thus  for  the  above  case  : 

+  1.  cyl.  ax.  ISO0  C  +  2.  cyl.  ax.  90°. 

But  such  lenses  cannot  be  ground  with  perfect  accuracy, 
and  are  far  more  expensive,  while  they  offer  no  advantage 
over  the  periscopic  formula. 

In  general,  the  full  correcting  cylinder  is  ordered,  in 
conjunction  with  the  needed  spherical  for  any  use.  But 
when  a  strong  lens  is  looked  through  obliquely,  its 
strength  is  so  increased  that  the  full  correcting  lens  might 
be  too  strong.  It  is  therefore  better  to  deduct  0.25  or 
0.50  D.  from  very  strong  cylinders  that  will  have  to  be 
looked  through  obliquely.  It  should  be  borne  in  mind 
also  that  when  a  strong  spherical  is  looked  through 
obliquely  it  has  the  effect  of  a  sphero-cylinder. 


186  ASTIGMATISM. 

Prognosis. — As  a  rule,  astigmatism  changes  but  little 
throughout  life.  In  some  cases,  however,  it  changes  very 
markedly.  It  is  especially  liable  to  change  in  rapidly 
growing  children,  and  at  about  the  age  of  fifty ;  and 
generally  in  eyes  that  are  rapidly  becoming  less  hyperopic 
or  more  myopic.  After  cataract  extraction,  or  other  cor- 
neal  injury,  the  resulting  astigmatism  reaches  its  height 
in  a  few  days  after  the  complete  closure  of  the  corneal 
wound,  and  then  slowly  subsides,  the  permanent  condi- 
tion not  being  reached  sometimes  for  several  months. 

ABERRATION. 

The  cornea  is  always  more  curved  at  its  center  and 
flattened  toward  its  periphery.  The  crystalline  lens  is 
flatter  at  the  center  and  more  convex  at  its  periphery. 
These  usually  balance  each  other  near  the  center  of  the 
pupil,  causing  an  area,  the  visual  zone,  the  refraction  of 
which  usually  compares  well  with  that  of  artificial  opti- 
cal instruments.  But  at  the  periphery  of  the  dilated 
pupil,  either  the  flattening  or  the  increased  curvature 
predominates,  causing  aberration. 

If  the  increased  curvature  predominates,  so  that  the 
eye  is  more  myopic  or  less  hyperopic  at  the  edge  of  the 
pupil  than  at  the  center,  it  is  called  positive  abewation. 
This  resembles  the  aberration  of  a  spherical  lens.  It  is 
the  more  common  form.  If  the  flattening  predominates 
at  the  edge  of  the  pupil,  making  it  less  myopic  or  more 
hyperopic  than  at  the  center,  it  is  called  negative  aberra- 
tion. The  difference  between  the  refraction  of  the  center 
of  the  pupil  and  that  of  the  margin  often  amounts  to 
1.  D.  or  over. 

Aberration  interferes  with  the  measurement  of  ame- 
tropia.  It  is,  next  to  accommodation,  the  most  serious 
obstacle  to  accurate  measurements  with  the  refraction 
ophthalmoscope,  and  makes  it  necessary  in  skiascopy 
to  come  near  the  patient,  to  get  the  movement  of  light 
and  shade  in  the  visual  zone  at  the  center  of  the  pupil, 
which  may  be  directly  opposite  to  the  movement  at  the 


ABERRATION.  187 

edge  of  the  pupil.    These  two  areas  of  light  that  it  causes 
in  the  pupil  are  shown  in  Fig.  74. 

In   exceptional   cases   it   causes  the  patient  to  select 
under  a  mydriatic  a  lens  which  will  not  suit  him  when 


A  B 

FIG.  74.— Appearance  of  the  pupil  in  aberration  :  A,  from  near  the  point  of 
reversal  for  the  extra-visual  zone  near  the  margin  of  the  pupil ;  B,  from  near 
the  point  of  reversal  of  the  visual  zone  at  the  center  of  the  pupil. 

the  pupil  has  contracted.  With  negative  aberration  he 
may  choose  under  a  mydriatic  a  convex  lens  too  strong  to 
allow  of  clear  distant  vision  when  the  mydriatic  has 
passed  off.  The  aberration  should  be  examined  by  skias- 
copy  in  each  case  of  refractive  error.  The  cases  of 
greatest  aberration  (negative)  are  those  of  conical  cornea, 
in  which  the  apex  of  the  cone  may  be  20.  or  30.  D. 
myopic,  while  the  periphery  of  the  pupil  is  even  hyper- 
opic.  Aberration,  usually  negative,  also  appears  as  the 
result  of  the  lens-changes  preceding  cataract. 

IRREGULAR  ASTIGMATISM. 

Irregular  astigmatism  exists  in  all  eyes.  Usually  it  is 
confined  to  the  periphery  of  the  dilated  pupil ;  but  often 
a  low  degree  of  it  may  be  detected,  by  skiascopy,  at  the 
center  of  the  pupil.  The  term  includes  interference  with 
refraction  caused  by  all  irregularities  of  the  cornea  or 
crystalline  lens.  Typical  forms  are  caused  by  the  altera- 
tions in  the  cornea  that  follow  keratitis,  and  by  the 
changes  in  the  crystalline  lens  that  precede  senile  cataract. 
It  causes  impairment  of  vision,  and  interferes  with  the 


188  IRREGULAR  ASTIGMATISM. 

various  tests  for  ametropia.  It  may  also  cause  monocular 
polyopia,  multiple  images  of  objects,  especially  of  the 
moon  or  sources  of  artificial  light,  by  reason  of  different 
parts  of  the  cornea  or  lens  forming  each  its  separate 
image  on  the  retina.  The  parts  of  the  pupil  which  form 
the  particular  images  can  be  ascertained  by  noticing  the 
effect  of  covering  particular  portions  of  the  pupil.  What 
has  been  called  normal  irregular  astigmatism  by  Donders 
is  partly  aberration.  It  causes,  when  the  pupil  is  dilated 
by  darkness,  the  rays  which  most  eyes  see,  extending  from 
a  point  of  light,  as  a  star  or  distant  arc  light. 

Irregular  astigmatism  cannot  be  corrected  by  any  lens. 
Narrowing  of  the  pupil  diminishes  its  effect.  Spectacles 
with  an  opaque  disk  having  a  small  opening,  or  a  narrow 
slit  in  it,  called  stenopaic  spectacles,  sometimes  improve 
vision.  But  they  can  rarely  be  worn,  because  they  limit 
the  field  of  vision  so  much.  Often  there  is  with  high 
irregular  astigmatism  some  small  part  of  the  cornea 
presenting  regular  astigmatism,  hyperopia,  or  myopia, 
the  correction  of  which  will  give  the  patient  greatly 
improved  vision.  Such  areas  should  be  carefully  sought 
for  and  corrected. 

ANISOMETROPIA. 

Anisometropia,  or  inequality  in  the  refraction  of  the 
two  eyes,  exists  in  slight  degree  in  a  very  large  propor- 
tion of  cases.  The  term  is  usually  applied  only  to  cases 
presenting  great  differences  between  the  two  eyes,  or 
when  one  eye  is  hyperopic,  and  the  other  myopic,  for 
which  state  antimetropia  is  also  used.  If  the  difference 
of  refraction  is  small — 1.  D.  or  less — each  eye  is  given  its 
correcting  lens.  This  plan  can  often  be  followed  until 
the  difference  amounts  to  2.  or  2.5  D.,  although  in  these 
cases  it  is  sometimes  better  to  weaken  slightly  the 
stronger  of  the  two  lenses.  When  the  difference  is 
greater  than  2.5  D.,  each  eye  may  be  given  its  correcting 
lens  in  some  cases ;  but  sometimes  it  is  best  to  give  the 
correcting  lens  for  the  better  eye,  and  one  of  about  the 
same  strength  for  the  other. 


ERRORS  OF  REFRACTION.  189 

THE  MOUNTING  AND  WEARING  OF  GLASSES. 

Lenses,  to  be  of  service,  must  be  properly  mounted 
and  worn.  Spectacle  frames  are  superior  to  eye-glasses 
(pince-nez)  for  strong  cylinders  ;  the  former  generally  can 
be  more  accurately  adjusted,  and  keep  their  place  better. 
Eye-glasses,  however,  because  of  their  appearance,  will 
sometimes  be  worn  when  spectacles  would  not.  They  are 
more  convenient  for  slipping  on  and  off,  if  this  must 
frequently  be  done,  as  with  glasses  used  for  presbyopia. 

In  any  frame  the  lenses  must  be  mounted  so  as  to  take 
their  proper  position  before  the  eyes.  They  must  have  the 
proper  distance  between  their  centers  (usually  the  pupil- 
lary distance) ;  and  must  stay  permanently  at  the  proper 
height,  not  slip  down  because  the  nose-piece  is  too  high. 
They  must  be  the  proper  distance  before  the  eyes,  usually 
just  far  enough  away  to  escape  being  touched  by  the 
lashes ;  and  they  must  have  such  an  inclination  that 
when  in  use  the  eyes  will  look  as  nearly  perpendicular  to 
the  surfaces  of  the  glass  as  possible — that  is,  for  distance 
the  glass  should  face  directly  forward ;  for  near-seeing 
they  should  face '  somewhat  downward. 

When  used  for  looking  in  different  directions  glasses 
should  be,  as  far  as  possible,  periscopic — that  is,  concave 
toward  the  eye,  convex  from  it.  This  is  secured  by 
using  meniscus  spherical  lenses,  or  the  periscopic  combi- 
nation of  sphero-cylindrical  lenses.  In  general,  in  mount- 
ing any  lens,  the  more  concave  side  should  be  placed 
toward  the  eye,  the  more  convex  from  it. 

Tlic  Period  of  Adaptation. — Seeing  through  a  pair  of 
new  lenses  demands  a  new  co-ordination  of  the  nervous 
and  muscular  actions  concerned  in  vision,  which,  like  any 
other  new  exercise,  requires  time  to  master.  Until  the 
new  actions  have  become  customary  and  automatic,  the 
best  help  will  not  be  obtained  from  the  glasses.  The 
hyperope  may  have  trouble  in  relaxing  his  accommoda- 
tion so  as  to  let  the  glass  do  the  work.  The  myope  may 
at  first  find  it  an  effort  to  keep  up  the  accommodation 
needed  for  near-seeing.  Lenses  of  unequal  strength,  for 


190  ADAPTATION  TO  GLASSES. 

correcting  unsymmetrical  astigmatism,  cause  apparent 
distortion  of  objects  (binocular  metamorphopsia)  and  con- 
fusion of  perspective,  that  may  not  wholly  disappear  for 
many  months. 

If  the  new  lenses  correct  a  considerable  degree  of 
refractive  error,  previously  uncorrected,  the  patient  should 
be  informed  that  they  will  not  be  entirely  comfortable  at 
first.  The  necessary  period  of  adaptation  will  be  some- 
what proportioned  to  the  patient's  age,  varying  from  a  day 
or  two  in  children,  to  two  or  three  months  or  even  longer 
in  old  people.  If  the  patient  be  not  informed  of  these 
difficulties  at  the  time  of  getting  his  glasses,  he  will  think 
that  there  has  been  some  mistake  about  them,  and  may 
meet  subsequent  explanations  with  incredulity. 

BIBLIOGRAPHY. 

The   Full   Correction  of  Myopia.     G.  C.  Harlan   and  E.  Jackson, 

"Trans.  Amer.  Ophthalmol.  Soc.,"  1892. 
School  Hygiene.    S.  D.  Risley,   "System  of  Diseases  of  the  Eye," 

vol.  ii. 
Myopia,    the    Result    of   Constitutional   Disease.      R.   D.    Batten, 

"Ophthalmic  Review,"  Jan.,  1892. 
Operative   Correction   of  Myopia.      Thier,    Fukala,    and    Pergens, 

"Ophthalmic  Review,"  Apr.,  1895. 
Removal  of  the  Lens  for   High  Myopia.     E.  Jackson,  "  Ophthal. 

Rec.,"  Feb.,  1898. 
Operative  Treatment  of  High  Myopia.     H.  D.  Noyes,  W.  H.  Wil- 

mer,   R.   Saltier,   and  others,   "Trans.  Amer.  Ophthal.  Soc.," 

1898. 
Final    Results   of  Operative   Treatment   of    Myopia.     O.  Scheffels, 

"  Amer.  Jour,  of  Ophthalmol.,"  Jan.,  1899. 
Practical  and  Theoretical  Treatise  on  Astigmatism.     S.  M.  Burnett, 

245  pp.,  J.  H.  Chambers  &  Co.,  St.  Louis. 
Normal  Corneal  Astigmatism.     H.   V.  Wiirdemann,  "  Trans.  Sect. 

on  Ophthal.,  Amer.  Med.  Assoc.,"  1892. 
Tests  for  Astigmatism.     John  Green,  "Trans.   Amer.  Ophthalmol. 

Soc.,"   1868. 
An   Instrument   for   the   Diagnosis  of    Refraction.     W.    Thomson, 

"Trans.  Amer.  Ophthal.  Soc.,"  1873,  1878. 
Ophthalmometry   and    Its   Clinical   Applications.      A.   Javal,    Jr., 

"System  of  Diseases  of  the  Eye,"  vol.  ii. 
Reid's  Portable  Ophthal mometer.     Jas.  Hinshelwood,  "  Ophthalmic 

Review,"  Nov.,  1897. 
Form   of    Retinal    Images   in   the  Astigmatic   Eye.      Carl   Roller, 

"  Trans.  Amer.  Ophthal.  Soc.,"  1892. 


ERRORS  OF  REFRACTION.  191 

The  Equivalent  Refraction  of  Two  Cylindrical  Lenses.  H.  Wil- 
son, ''  Archives  of  Ophthalmol.,"  Jan.,  1898. 

Variations  of  Power  in  Obliquely  Placed  Lenses.  John  Green, 
"Trans.  Amer.  Ophthalmol.  Soc.."  1895. 

Astigmatism  Following  Cataract  Extraction.  E.  Jackson,  "Trans. 
First  Pan-American  Med.  Cong.,  1893 ;  Trans.  Sect,  on  Oph- 
thal.,  Amer.  Med.  Assoc.,"  1897. 

Surgical  Treatment  of  Astigmatism.  J.  Lucciola,  ''Ophthalmic 
Review,"  Dec.,  1896. 

The  Correction  of  Anisornetropia.  Edward  Jackson,  "  Arner.  Jour, 
of  Ophthalmol.,"  Oct.,  1896. 

The  vSymrnetrical  Aberration  of  the  Eye.  "  Trans.  Amer.  Ophthal- 
mol. Soc.,"  1888. 

Effects  of  Lid  Pressure  on  the  Cornea.  G.  J.  Bull,  "Trans.  Eighth 
Internat.  Ophthalmol.  Cong.,"  Edinburgh,  1893. 

Contact  Lenses.     H.  Dor,  "Ophthalmic  Review,"  Jan.,  1894. 

The  Value  of  Weak  Lenses.  H.  M.  Starkey,  "Trans.  Sect,  on 
Ophthalmol.,  Amer.  Med.  Assoc.,"  1894. 

Spectacles  and  Eye-glasses:  Their  Forms,  Mounting,  and  Proper 
Adjustment.  R.  J.  Phillips,  105  pp.,  P.  Blakiston's  Son  &  Co., 
Philadelphia,  Pa. 

Method  in  the  Use  of  Test  Lenses.  Edward  Jackson,  "  Annals  of 
Ophthalmology  and  Otology,"  July,  1893. 


CHAPTER   VIII. 

DISORDERS  OF  THE  OCULAR  MOVEMENTS. 

MOVEMENTS  of  the  eyeball  are  required  to  place  the 
most  sensitive  part  of  the  retina  where  it  will  receive  the 
image  of  the  object  especially  looked  at;  to  keep  the 
eye  turned  in  the  desired  direction,  during  movements  of 
the  head  and  body  that  would  otherwise  displace  it ;  and 
to  keep  the  two  eyes  directed  toward  the  same  point,  to 
secure  images  which  by  fusion  will  give  binocular  vision. 
There  may  be  inability  to  execute  these  movements,  or 
they  may  be  accomplished,  but  by  undue  effort. 

If  an  eye  is  so  directed  that  the  image*  of  the  point  on 
which  attention  is  fixed  falls  upon  the  fovea,  the  eye  is 
said  to  fix  that  point.  Normally,  both  eyes  "fix"  the 
same  point.  If,  however,  one  of  them  does  not  fix  the 
point  looked  at,  but  has  its  visual  line  directed  elsewhere, 


192  FIXATION  AND  SQUINT. 

it  is  said  to  deviate.  Such  an  eye  is  called  a  deviating  eye, 
the  other  is  called  a  fixing  eye.  The  point  "  fixed  "  is 
called  the  point  of  fixation,  the  angle  between  the  deviat- 
ing position  of  the  visual  line  and  its  normal  direction 
through  the  point  of  fixation  is  the  angle  or  degree  of 
squint.  An  eye  which  deviates  is  said  to  squint.  The 
deviation  constitutes  the  abnormal  condition  of  squint  or 
strabismus. 

Ocular  Movements. — The  normal  extent  of  the 
ocular  movements  varies  with  the  general  muscular 
power,  and  with  the  form  and  prominence  of  the  eye- 
balls and  their  relations  to  the  orbit.  The  eyes  can  gen- 
erally be  turned  from  forty-five  degrees  to  fifty-five 
degrees  to  either  the  right  or  the  left,  a  total  excursion 
horizontally  of  ninety  degrees  to  one  hundred  degrees, 
and  they  are  capable  of  a  total  vertical  movement  of 
seventy-five  degrees  to  one  hundred  degrees.  These  move- 
ments carry  the  eye  outward  until  the  outer  margin  of 
the  cornea  is  behind  the  external  canthus,  inward  until 
the  inner  corneal  margin  touches  the  plica  and  caruncle, 
and  up  or  down  to  where  the  margin  of  the  cornea  passes 
considerably  behind  the  widely  opened  lids.  As  the 
limits  of  movement  in  any  direction  are  reached,  the 
effort  becomes  fatiguing  or  painful,  and  the  eye  tends  to 
oscillate,  exhibiting  a  kind  of  normal  nystagmus. 

Although  the  eyes  are  commonly  so  directed  that  their 
visual  lines  meet  in  the  point  looked  at,  and  their  move- 
ments are  so  co-ordinated  as  to  preserve  this  relation  con- 
st mtly,  it  is  a  relation  that  can  be  changed  within  certain 
links.  Thus,  the  visual  lines  commonly  lie  in  the  same 
plane,  passed  through  the  fovea  of  each  eye  and  the  point 
fixed.  But  one  eye  may  be  made  to  turn  up  or  down  more 
than  the  other.  It  will  do  so  to  prevent  double  vision, 
if  a  prism  be  placed  before  one  eye  with  its  base  down  or 
up.  The  power  of  doing  this  is  called  the  power  of 
sursumduction  or  sursumvergence.  It  varies  normally 
from  one  to  two  degrees — that  is,  double  vision  does  not 
occur  unless  the  prism  used  thus  is  as  strong  as  2  to 
4  centrads.  The  eyes  are  said  to  overcome  weaker 


DISORDERS  OF  OCULAR  MOVEMENTS.          193 

prisms  by  their  power  of  sursumduction.  If  prisms  be 
placed  before  one  or  both  eyes  with  their  bases  toward 
the  nose,  the  eyes  looking  at  a  distant  object  turn  out 
and  their  visual  lines  diverge,  to  "overcome"  the  prisms 
and  avoid  double  vision.  This  is  called  abduction  or 
prism-divergence.  Its  normal  extent  is  about  5  to  10 
centrads.  When  prisms  are  placed  before  the  eyes  with 
their  bases  toward  the  temple  the  eyes  turn  in  to  "  over- 
come "  them.  This  is  the  adduction  or  prism-convergence. 
Its  normal  limits  are  from  12  to  20  centrads.  The 
normal  relation  of  abduction  to  adduction  power  is  1  to 
2  or  1  to  3.  The  adduction  power  may  be  increased  by 
practice  ;  and  by  using  accommodation  and  rendering  the 
distant  object  indistinct,  the  eyes  can  be  converged  very 
much  more.  But  this  is  not  what  is  usually  meant  by 
the  power  of  adduction.  By  a  maximum  effort  the 
visual  lines  may  be  caused  to  converge  to  the  extent  of 
100  to  150  centrads  (60  degrees  to  85  degrees),  so  that 
they  will  meet  at  a  point  even  less  than  3  inches  from 
the  eyes.  This  power  of  converging  the  eyes  is  called 
the  power  of  convergence.  It  can  be  measured  by  the 
nearest  point  at  which  an  object  can  be  seen  single,  the 
near-point  of  convergence;  or  by  the  power  to  "overcome" 
prisms  with  their  bases  toward  the  temple,  if  the  patient 
has  learned  to  exert  his  full  power  in  this  way. 

THE   METER-ANGLE. 

When  the  eyes  look  at  a  point  directly  in  front  of 
them,  and  one  meter  away  from  each  eye — that  is,  when 
both  visual  lines  meet  one  meter  from  each  eye — 
in  the  perpendicular  to  the  line  joining  the  centers 
of  rotation  of  the  two  eyes  at  its  middle,  the  angle 
which  each  visual  line  will  make  with  this  perpendic- 
ular is  called  a  meter-angle.  Thus,  in  Fig.  75 :  Sup- 
jxjse  R  and  L  to  represent  the  centers  of  rotation  of  the 
two  eyes,  and  P  M  the  perpendicular  to  the  middle 
point  of  the  line  joining  R  and  L.  When  the  distance 
R  M  or  L  M  is  1  meter,  the  angle  R  M  P  or  the  angle 

13 


194  THE  METER- ANGLE. 

L  M  P  is  one  meter-angle.  If  the  distance  from  the  eye 
to  the  point  fixed,  as  R  M',  is  £  meter,  the  angle  R  M'  P 
equals  two  meter-angles.  If  the  distance  of  the  point  fixed 
is  £  of  a  meter,  the  angle  equals  three  meter-angles,  and  so 
for  other  distances.  The  number  of  meter-angles  of  con- 
vergence has  the  same  relation  to  the  distance  of  the 
point  fixed  as  the  strength  of  a  lens  in  diopters  has  to 


FIG.  75.— The  meter-angle. 

the  focal  distance  of  the  lens.  The  value  of  the  meter- 
angle  in  centrads  or  degrees  varies  with  the  distance 
between  the  centers  of  the  two  eyes.  Thus,  if  the  dis- 
tance between  the  centers  of  rotation  (regarded  in  practice 
as  equal  to  the  distance  between  the  centers  of  the  pupils) 
be  50  mm.,  the  meter-angle  equals  2.5  centrads  or  1.43 
degrees ;  for  60  mm.  it  is  3  centrads  or  1.72  degrees,  and 
for  70  mm.  it  is  3.5  centrads  or  2.005  degrees. 

PROJECTION   AND   DIPLOPIA. 

The  image  of  an  object  is  formed  on  the  retina  at  the 
point  where  a  straight  line  from  the  object,  through  the 
nodal  point  of  the  eye,  pierces  the  retina.  Conversely, 
when  an  image  is  formed  on  the  retina,  the  object  from 
which  light  comes  to  form  it  is  referred  or  "projected" 
in  the  direction  of  the  straight  line  from  that  point  of  the 
retina,  through  the  nodal  point  of  the  eye.  These  "  pro- 
jections" of  the  impressions  made  on  the  retina  by 
external  objects  become  by  experience  intimately  asso- 
ciated with  impressions  made  through  other  senses,  and 
with  them  serve  to  locate  the  objects. 


DISORDERS  OF  OCULAR  MOVEMENTS.          195 

When  the  two  eyes  are  fixed  on  the  same  point,  its 
image  falls  on  both  foveas.  These  are  corresponding 
points.  For  any  other  point  of  the  retina,  the  line  of 
projection  from  which  makes  a  certain  angle  with  the 
visual  line  of  that  eye,  there  is  a  point  in  the  other  retina 
from  which  the  line  of  projection  has  the  same  relation  to 
the  visual  line  of  that  eye.  Such  points  are  also  corres- 
ponding points.  When  the  two  eyes  are  fixed  on  a  cer- 
tain point,  impressions  of  the  point  fixed,  and  of  certain 
other  points,  fall  on  "  corresponding  points  "  of  the  two 
retinas.  These  points,  whose  images  fall  on  corresponding 
points  of  the  retinas,  constitute  a  surface  called  the 
ho  ropier.  Only  points  lying  on  the  horopter  can  make 
their  impressions  on  exactly  corresponding  points  of  the 
two  retinas.  All  points  lying  nearer  to  the  eyes  than  the 
horopter,  or  lying  beyond  it,  make  their  impressions 
on  parts  of  the  retina  that  do  not  exactly  correspond. 
Impressions  of  an  object  made  in  the  two  eyes  on  corres- 
ponding points  of  the  retina  give  rise  to  a  single  percep- 
tion of  the  object. 

If  the  points  of  the  two  retinas  almost  correspond, 
there  still  results  a  single  impression  ;  but  the  stereoscopic 
effect  by  which  we  judge  the  relative  distance  of  objects 
is  added.  If  the  points  on  which  the  impressions  are 
made  in  the  two  eyes  differ  too  widely  in  their  relation  to 
the  visual  line,  instead  of  the  stereoscopic  effect  there 
results  a  confused  perception.  If  the  points  differ  a  little 
more  widely  yet,  two  separate  perceptions  of  the  object 
arise,  and  are  referred  in  different  directions,  as  though 
belonging  to  different  objects.  This  perceiving  of  the 
objects  separately  by  the  two  eyes  constitutes  binocular 
diplopia,  or  double  vision. 

Such  diplopia  is  readily  produced  by  placing  a  finger- 
tip on  the  middle  of  the  lower  lid,  just  within  the  margin 
of  the  orbit,  and  pressing  slightly  backward.  Keeping 
both  eyes  steadily  open,  and  fixed  on  some  prominent 
object,  a  false  image  will  be  seen  to  separate  from  the 
true  one,  as  the  pressure  of  tissues  back  into  the  orbit 
causes  the  eye  to  rotate  downward.  The  student  should 


196  PROJECTION  AND  DIPLOPIA. 

try  this  experiment  to  get  a  better  understanding  of 
certain  points  in  regard  to  squint  and  diplopia. 

The  departure  from  exact  correspondence  between 
the  points  on  which  the  impressions  are  made  in  the 
two  eyes,  necessary  to  cause  diplopia,  varies  for  dif- 
ferent parts  of  the  retina.  At  the  fovea,  where  nor- 
mally the  impressions  are  always  made  at  exactly 
corresponding  points,  the  slightest  lack  of  correspondence 
causes  confusion,  and  is  extremely  annoying.  On  the 
periphery  of  the  retina,  where  there  is  generally  a  lack 
of  exact  correspondence  in  the  impressions,  they  may  fall 
on  widely  different  points,  yet  diplopia  may  not  be  per- 
ceived or  will  not  be  annoying.  Separation  of  peripheral 
impressions  constantly  occurs,  and  habitually  passes  un- 
noticed. But  it  can  be  perceived  and  studied  thus  :  Hold 
two  pencils  in  a  line  writh  the  nose,  one  6  inches  in  front 
of  the  face,  the  other  12  inches  in  front  of  it.  On  fixing 
the  eyes  on  the  nearer  pencil,  the  more  distant  one  will 
appear  double,  its  image  falling  not  on  corresponding 
parts  of  the  two  retinas,  but  on  the  nasal  side  of  the  fovea 
in  both.  On  fixing  the  eyes  on  the  more  distant  pencil, 
the  nearer  one  will  likewise  appear  double,  its  images 
falling  on  the  temporal  portions  of  both  retinas,  instead 
of  corresponding  points,  which  would  be  the  temporal 
side  of  one  retina  and  the  nasal  side  of  the  other.  In 
this  experiment,  as  in  all  physiological  use  of  the  eyes, 
the  images  at  the  foveas  exactly  correspond,  hence  the 
diplopia  is  not  annoying,  but  may  be  even  difficult  to 
discover.  When  the  fixation-point  is  also  involved  in 
the  lack  of  correspondence  between  the  two  rotinal  im- 
pressions, the  diplopia  is  obvious  and  annoying.  It  can- 
not generally  be  ignored. 

When  a  seeing  eye,  which  previously  has  fixed  nor- 
mally with  its  fellow,  begins  to  deviate,  diplopia  results, 
and  the  variety  of  the  diplopia  varies  with  the  direction 
of  the  deviation.  The  eye  which  still  fixes  properly 
receives  the  image  of  the  object  looked  at  upon  its  fovea  ; 
and  projects  it  in  its  true  direction — the  tme  image.  The 
deviating  eye  receives  the  impression  on  some  other  part 


DISORDERS  OF  OCULAR  MOVEMENTS.          197 

of  the  retina  and  projects  it  in  some  other  direction,  as  a 
second  object  of  the  same  kind — the  false  image.  The 
relation  of  these  to  one  another  can  best  be  illustrated 
thus :  Suppose  Fig.  76  to  represent  a  case  of  convergent 
squint  in  which  R  is  the  fixing  and  L  the  deviating  eye. 
In  R,  the  image  of  0,  the  point  looked  at,  falls  at  the 
fovea.  But  in  L  the  image  of  0  falls  elsewhere  at  /. 


FIG.  76.— The  projection  of  the  false  image  in  squint. 

Hence,  the  projection  of  the  false  image  seen  by  L  will 
not  correspond  to  the  projection  of  the  true  image  seen  by 
.R,  but  will  be  in  the  direction  of  Ft  the  line  /'  F 
making  with  the  visual  line  R  O  the  same  angle  as  /  0 
makes  with  the  visual  line  L  S. 

It  should  be  noted  that  if  the  deviating  eye  be  turned 
up,  the  impression  of  the  object  fixed  is  made  on  the 
upper  part  of  the  retina,  and  the  false  image  is  projected 
below  the  true  image.  If  the  deviating  eye  be  turned  to 
the  right,  the  impression  is  made  on  the  right  half  of  its 
retina,  and  the  false  image  is  projected  to  the  left  of  the 
true  image.  In  general,  the  false  image  is  projected  in  a 
direction  from  the  true  image,  the  opposite  of  that  in 
which  the  eye  deviates. 

When  the  image  seen  by  the  right  eye  appears  to  the 
right,  and  that  belonging  to  the  left  eye  to  the  left,  the 
diplopia  is  called  homonymous.  When  the  image  belong- 
ing to  the  right  eye  is  seen  to  the  left,  and  that  belonging 
to  the  left  eye  appears  more  to  the  right,  it  is  crossed 
diplopia.  Homonymous  diplopia  occurs  when  the  eyes 
are  crossed,  and  crossed  diplopia  when  the  eyes  diverge. 


198  DIPLOPIA. 

Diplopia  is  more  annoying  in  proportion  to  the  previous 
perfection  of  binocular  vision,  the  suddenness  of  its  occur- 
rence, the  age  of  the  patient,  and  the  nearness  of  the  false 
image  to  the  true  image.  Where  the  power  of  binocular 
vision  has  never  developed,  as  in  patients  affected  with 
squint  from  infancy,  diplopia  is  never  noticed,  and  it  may 
be  impossible  to  provoke  it.  When  the  vision  of  one  eye 
is  very  imperfect,  diplopia  causes  little  annoyance.  With 
high  degrees  of  squint,  too,  diplopia  is  not  troublesome, 
because  the  false  image  falls  so  far  from  the  fovea. 
In  squint  of  long  standing,  especially  if  developed  in 
childhood,  the  annoyance  of  diplopia  is  avoided  by  habit- 
ually disregarding  the  impression  made  on  the  deviating 
eye,  much  as  one  accustomed  to  the  use  of  the  ophthal- 
moscope, microscope,  or  other  monocular  optical  instru- 
ment, learns  to  disregard  the  visual  impressions  made  on 
his  unused  eye,  and  to  work  with  both  eyes  open. 

AMBLYOPIA  WITH  SQUINT. 

It  has  been  supposed  that  this  disregarding  or 
"  suppression "  of  visual  impressions  made  on  the 
deviating  eye  reacted  unfavorably  on  its  visual  acute- 
ness,  causing  in  a  large  proportion  of  cases  a  special 
condition  designated  amblyopia  ex  anopsia.  The  facts 
probably  are  that  sometimes  a  "  suppression  "  of  the  image 
of  one  eye  causes  at  least  temporary  inability  to  use  it. 
Then  visual  acuteness,  and  especially  the  power  to  recog- 
nize letters,  is  partly  a  matter  of  education ;  and  eyes 
deviating  and  not  fully  used  for  accurate  seeing  from 
early  childhood,  lack  the  development  of  visual  acuity 
they  would  otherwise  have  attained.  But  in  a  larger 
proportion  of  cases  vision  is  defective  before  the  eye 
squints,  and  the  amblyopia  helps  to  cause  the  squint. 

Causes  of  Squint. — Congenital  inability  to  turn  the 
eyes  in  certain  directions  is  rare,  but  cases  occur.  It  will 
be  referred  to  under  Paralytic  Squint.  Incomplete  power 
of  binocular  co-ordination  is  much  more  common.  This 
might  be  expected  from  the  extremely  complex  character 


DISORDERS  OF  OCULAR  MOVEMENTS.          199 

of  the  adjustments  required  and  the  comparatively  recent 
evolution  of  the  power  of  binocular  vision.  The  general 
causes  of  acquired  squint  are  paralysis  of  one  or  more  of 
the  ocular  muscles;  and  imperfect  vision  in  one  eye, 
either  from  opacity  of  the  media,  distortion  of  its  dioptric 
surfaces,  or  disease  of  the  choroid,  retina,  or  optic  nerve, 
rendering  it  unable  to  participate  in  binocular  vision. 
Hyperopia,  myopia,  and  other  special  causes  will  be  con- 
sidered with  the  particular  forms  of  squint  which  they 
occasion. 

Diagnosis  of  Squint. — The  evidence  of  squint  is 
often  revealed  by  the  most  casual  inspection  of  the  eyes. 
Still  the  most  obvious  appearance  of  squint  may  be  mis- 
leading. We  judge  the  direction  of  the  eyes  by  the 
direction  of  the  cornea ;  and  when  the  visual  line  pierces 
the  cornea  at  the  usual  point  a  little  to  the  nasal  side  of 
the  center,  we  can  thus  judge  correctly.  When,  however, 
the  visual  line  pierces  the  cornea  at  a  distance  from  its 
center,  the  cornea  will  appear  to  be  turned  in  one  direc- 
tion, while  the  visual  line  is  really  directed  somewhere 
else.  The  eye  will  appear  to  squint,  when  really  both 
eyes  have  their  visual  lines  directed  to  the  point  fixed ; 
or  it  will  appear  to  be  properly  directed  when  really 
squinting.  The  appearance  of  squint  must  therefore  be 
confirmed  by  careful  tests. 

The  Cover-test. — If  both  eyes  possess  useful  vision, 
the  covering  of  the  squinting  eye  compels  the  patient  to 
"  fix  "  with  what  was  previously  the  deviating  eye.  This 
he  may  do  by  turning  the  head,  in  a  case  of  paralytic, 
squint,  or  by  simply  turning  the  eyes  in  a  case  of  comi- 
tant  squint.  The  eye  which  had  previously  deviated 
turns,  so  as  to  fix  the  point  at  which  the  patient  is  trying 
to  look  ;  and  the  eye  that  had  fixed  turns  elsewhere — 
deviates.  Thus,  by  covering  the  fixing  eye,  the  deviation 
or  squint  is  transferred  from  one  eye  to  the  other.  By 
shifting  the  cover  from  one  eye  to  the  other  the  squint  is 
transferred  back  and  forth.  The  cover,  which  may  be 
the  hand  or  a  piece  of  cardboard,  held  in  front  of  the 
eye,  should  be  far  enough  in  front  to  allow  the  surgeon  to 


200  DIAGNOSIS  OF  SQUINT. 

watch  the  movement  that  occurs  behind  it ;  but  it  must 
be  so  held  as  certainly  to  interrupt  the  patient's  view 
with  the  covered  eye. 

The  direction  from  which  the  eyes  move  when  the 
cover  is  shifted  indicates  the  direction  of  the  squint. 
Thus,  if  on  uncovering  the  right  eye,  it  moves  to  the 
right  to  fix  the  object,  it  must  have  been  deviating  to  the 
left — convergent  squint ;  if  it  moves  upward,  it  was 
deviating  downward — vertical  squint ;  if  it  moves  to  the 
left,  it  was  deviating  to  the  right — divergent  squint. 

Power  of  Moving  Eyes  in  Different  Directions. — 
Having  ascertained  that  squint  is  actually  present,  we 
must  next  determine  is  it  comitant  (concomitant}  squint 
or  paralytic  squint.  This  may  be  done  by  watching  the 
behavior  of  the  eyes  when  they  attempt  to  fix  an  object 
held  successively  in  different  directions.  The  patient 
may  be  directed  to  fix  continuously  the  end  of  a  finger  or 
a  lead  pencil,  which  the  surgeon  holds  first  in  one  part 
of  the  field  and  then  in  another.  If  the  squint  be 
comitant,  it  remains  substantially  the  same,  whatever  the 
direction  in  which  the  eyes  are  turned.  If,  however,  the 
squint  be  due  to  the  weakness  or  paralysis  of  some  par- 
ticular muscle  or  muscles,  the  eyes  move  and  fix  normally 
together,  so  long  as  the  affected  muscle  or  muscles  are  not 
called  upon.  But  when  the  contraction  of  the  affected 
muscle  is  necessary  for  the  movement  required  of  one  of 
the  eyes,  that  eye  will  lag  behind  its  fellow,  will  no 
longer  fix  the  object,  but  will  deviate ;  and  the  stronger 
the  contraction  required  of  the  paralyzed  muscle  the 
greater  the  deviation.  The  direction  of  the  movement 
which  the  squinting  eye  fails  to  execute  shows  which 
muscle  is  affected.  Thus,  if  the  right  eye  fails  to  turn 
upward  with  the  left,  the  right  superior  rectus  is  at  fault ; 
if  it  fails  to  turn  to  the  right,  the  right  external  rectus 
does  not  properly  perform  its  function  ;  if  it  lags  on  look- 
ing down,  the  inferior  rectus ;  on  turning  the  eye  to  the 
left,  the  internal  rectus  is  responsible  for  the  deviation. 

The  test  of  movements  in  the  different  directions 
should  include  a  trial  of  the  power  of  convergence  by 


DISORDERS  OF  OCULAR  MOVEMENTS.          201 

holding  the  point  looked  at  in  the  median  plane  and 
bringing  it  steadily  toward  the  nose  until  the  patient  can 
no  longer  fix  it  with  both  eyes,  but  is  compelled  to  allow 
one  of  them  to  deviate.  The  nearest  point  that  can  be 
fixed  by  both  eyes  at  once  is  the  near-point  of  con- 
vergence. 

Measuring  the  Amount  of  Squint.  —  Having 
ascertained  the  presence  of  squint  and  its  variety,  the 
next  step  is  to  measure  its  degree.  The  old  plan  of 
measuring  the  deviation  of  the  eye  upon  a  rule  held 
before  it,  or  laid  along  the  edge  of  the  lower  lid  has  been 
discarded  for  more  accurate  methods.  One  of  these  is 
by  the  perimeter.  The  arc  of  the  perimeter  being 
turned  in  the  direction  in  which  the  eye  deviates,  the 
squinting  eye  is  placed  at  the  center  of  the  arc,  just  as 
for  the  taking  of  its  visual  field.  The  fixing  eye  is  then 
turned  toward  some  distant  point,  as  some  point  across 
the  room,  exactly  in  the  line  of  the  axis  of  the  instru- 
ment. The  deviating  eye  would,  if  properly  directed, 
look  toward  the  same  point  in  the  axis  of  the  instrument. 
The  surgeon,  noting  where  this  eye  is  directed,  reads  from 
the  graduation  of  the  arc  the  number  of  degrees  of  devia- 
tion. To  determine  exactly  the  direction  in  which  the 
eye  is  turned,  the  surgeon's  eye  is  moved  along  the  arc 
of  the  perimeter,  with  a  candle-flame  just  in  front  of  it, 
and  when  the  reflection  of  the  flame  from  the  patient's 
cornea  appears  to  be  in  the  center  of  the  pupil,  the  desired 
direction  of  the  deviating  eye  has  been  found.  For  the 
candle-flame  may  be  substituted  an  ophthalmoscopic  mir- 
ror reflecting  a  flame  placed  elsewhere. 

To  measure  the  degree  of  squint  by  the  tangent  of  the 
angle  of  deviation,  the  surgeon  places  his  eye  1  meter 
from  the  patient,  in  the  dark  room,  and  with  the  ophthal- 
moscopic mirror  throws  the  light  on  the  patient's  devi- 
ating eye  and  watches  its  corneal  reflex.  The  patient 
fixes  the  surgeon's  finger  held  1  meter  away  and 
moved  in  the  direction  opposite  to  that  in  which  the  eye 
deviates,  until  the  corneal  reflection  of  the  light  appears 
in  front  of  the  center  of  the  pupil.  When  this  is  the 


202  MEASURING  SQUINT. 

case,  the  patient's  "  deviating  eye  "  is  directed  toward  the 
surgeon'  s  eye  and  the  ophthalmoscopic  mirror,  while  his 
"  fixing  eye  "  is  directed  toward  the  surgeon's  finger.  The 
distance  from  the  surgeon's  eye  to  the  finger  is  the  tangent 
to  the  angle  of  deviation.  It  may  be  measured  on  a  tape- 
measure  or  meter-stick,  on  which  may  be  laid  off  a  scale 
of  tangents.  Approximately,  each  centimeter  means  an 
angular  deviation  of  1  centrad,  or  the  deviation  of  a  1 
degree  prism. 

The  tests  as  above  described  do  not  give  exactly  the 
deviation  of  the  visual  line,  but  the  deviation  of  a  line 
drawn  through  the  center  of  curvature  of  the  cornea  and 
the  center  of  the  pupil.  Any  notable  departure  of  this 
line  from  the  visual  line  may  be  observed  by  covering 
the  patient's  fixing  eye  and  having  him  fix  the  sight-hole 
in  the  ophthalmoscopic  mirror  with  the  eye  that  ordinarily 
deviates,  and  noting  the  apparent  position  in  the  pupil  of 
the  corneal  reflex.  If  this  be  at  the  center  of  the  pupil, 
the  two  lines  in  question  coincide ;  if  it  be  not  at  the 
center  of  the  pupil,  its  position  is  to  be  noted ;  and  the 
reflex  must  be  brought  to  this  same  position  in  measuring 
the  degree  of  squint. 

The  Diplopia  Test. — If  the  patient  can  recognize 
binocular  diplopia,  it  gives  the  most  accurate  means  of 
measuring  the  degree  of  squint.  It  can  be  most  favor- 
ably tested  by  having  the  patient  gaze  at  a  small  flame 
4  meters  distant  in  a  dimly  lighted  room.  If  there  is 
difficulty  in  observing  the  false  image,  on  account  of  the 
extreme  deviation  or  imperfect  vision  of  the  squinting  eye, 
the  fixing  eye  may  be  covered  with  dark  glass  to  dimin- 
ish the  vividness  of  its  image ;  or  with  the  hand  for  a 
little  time,  to  allow  the  patient  to  notice  the  image  belong- 
ing to  the  deviating  eye,  before  letting  the  other  image 
appear. 

When  the  two  images  have  been  certainly  recognized, 
the  covering  of  one  eye  causes  its  image  to  disappear, 
indicating  which  image  belongs  to  it.  Or  the  better  eye 
may  be  covered  with  a  colored  glass  to  lessen  the  bright- 
ness of  its  image  and  distinguish  it  by  color. 


DISORDERS  OF  OCULAR  MOVEMENTS.          203 

To  measure  the  degree  of  squint  by  the  diplopia  test, 
prisms  are  placed  before  one  or  both  eyes  in  such  a  way 
as  to  bring  the  two  images  together.  The  strength  of  the 
prisms  required  to  do  this  is  a  measure  of  the  degree  of 
the  squint. 

In  general,  the  prism  must  be  placed  with  the  apex  in 
the  direction  in  which  the  eye  deviates.  For  instance,  in 
a  case  of  convergent  squint,  the  image  belonging  to  the 
right  eye  would  be  to  the  right,  and  that  of  the  left  eye 
to  the  left.  To  bring  them  together,  a  prism  must  be 
placed  before  the  right  eye  with  the  apex  to  the  left,  or 
before  the  left  eye  with  the  apex  to  the  right.  Other 
methods  of  detecting  and  measuring  squint  are  more 
appropriately  described  under  Heterophoria  or  Latent 
Squint. 

Varieties  of  Squint. — Strabismus,  due  to  the  par- 
alysis or  paresis  of  one  or  more  of  the  muscles  that  turn 
the  eye  in  the  orbit,  occurs  only  when  the  weakened  mus- 
cle is  called  on  to  perform  its  function.  There  is  actual 
limitation  of  movement  in  a  certain  direction.  This  is 
paralytic  squint.  In  contrast  to  this  are  the  cases  in 
which  deviation  depends  upon  a  wrong  co-ordination  of 
the  movements  of  the  two  eyes,  by  which  they  habitually 
converge  too  much  or  too  little,  so  that  the  visual  lines 
intersect  nearer  or  farther  than  the  object  fixed.  Or  the 
two  visual  lines  do  not  lie  in  the  same  plane,  one  going 
higher  than  the  other.  These  abnormal  relations  of  the 
visual  lines  are  maintained,  whatever  the  direction  of  the 
object  looked  at.  Squint  of  this  kind  is  called  comitant 
or  concomitant  squint. 

Paralytic  squint  may  amount  only  to  a  weakness  in  a  cer- 
tain muscle  or  muscles,  making  necessary  an  increased 
effort,  or  a  compensatory  action  on  the  part  of  the  other  mus- 
cles, to  execute  certain  movements.  This  constitutes  an  in- 
sufficiency of  the  muscle  or  muscles  in  question.  Comitant 
squint  may  amount  only  to  a  tendency  of  the  visual  lines 
to  deviate,  a  tendency  habitually  overcome  by  an  effort,  in 
the  interest  of  binocular  vision.  Such  a  tendency  is  ren- 
dered evident  when  on  covering  one  eye,  or  otherwise 


204  VARIETIES  OF  SQUINT. 

preventing  binocular  vision,  the  visual  lines  deviate. 
This  tendency  of  the  visual  lines  to  deviate  is  called 
heterophoria.  Heterophoria  has  been  used  as  synonym- 
ous with  insufficiency  of  the  ocular  muscles,  and  it  is 
convenient  to  consider  both  classes  of  cases  together  under 
the  heading  Latent  Squint.  The  term  "  insufficiency," 
however,  will  be  here  applied  to  the  cases  in  which  the 
latent  squint  appears  only  when  the  attempt  is  made  to 
use  a  certain  muscle  or  muscles,  or  to  execute  certain 
movements  like  convergence  ;  and  "heterophoria"  will  be 
applied  to  those  cases  in  which  the  tendency  to  deviation 
appears  during  all  sorts  of  ocular  movements. 

PARALYTIC  SQUINT. 

It  is  characteristic  of  a  squint  purely  paralytic  that, 
when  the  eyes  are  in  certain  positions,  no  squint  is  present. 
As  the  effort  is  made  to  turn  them  in  a  certain  direction, 
one  eye  commonly  executes  normal  movements,  while  the 
other  does  not  move  at  all,  or  moves  to  less  than  the 
normal  extent.  By  the  extent  of  the  failure  in  normal 
movement,  it  "  deviates  "  from  a  normal  position. 

Causes  of  paralytic  squint  may  affect  either  the  mus- 
cles themselves,  the  nerve-trunks,  or  the  nerve-centers. 
Those  affecting  the  muscles  themselves  are  chiefly  wounds, 
or  the  cicatrices  caused  by  wounds,  suppuration,  or  new 
growths  involving  the  muscle.  Lesions  of  the  nerve- 
trunks  are  most  frequent.  They  occur  by  swelling  of 
adjoining  structures  or  hemorrhage,  or  are  caused  by 
syphilis,  rheumatism,  renal  and  vascular  disease,  influenza, 
and  other  acute  diseases.  Degenerations  due  to  exposure, 
alcoholism,  or  other  toxic  influences,  may  affect  either  the 
nerve-trunks  or  the  nuclei  from  which  they  arise. 
Paralytic  squint  may  be  congenital. 

Varieties. — Each  of  the  six  ocular  muscles  may  be 
paralyzed  alone,  giving  rise  to  its  peculiar  form  of  diplopia; 
or  the  palsies  of  two  or  more  muscles  may  be  combined 
in  various  ways.  The  paralysis  of  the  muscles  supplied 
by  a  certain  nerve-trunk  is  a  common  association.  Thus, 


DISORDERS  OF  OCULAR  MOVEMENTS.          205 

we  have  paralysis  of  the  oculomotor  nerve,  involving  the 
superior,  internal,  and  inferior  recti,  and  the  inferior 
oblique  with  the  elevator  of  the  lid,  the  ciliary  muscle, 
and  the  sphincter  of  the  iris. 

Recurrent  oculomotor'  paralysis  is  a  special  form  which 
occurs  in  early  life.  The  attack  begins  with  extreme 
headache,  chiefly  of  one  side  of  the  head,  nausea,  and 
vomiting,  and  edema  and  swelling  of  the  orbital  tissues 
and  lids  of  the  affected  side.  After  a  few  days  the  pain 
and  swelling  subside,  the  muscles  regain  their  power,  and 
the  patient  continues  well  for  a  period  varying  from  a 
few  days  to  many  months,  then  a  similar  attack  occurs. 
After  a  number  of  such  attacks  the  ocular  muscles  fail  to 
regain  their  power,  and  there  remains  complete  and  perma- 
nent oculomotor  paralysis  with  recurrent  attacks  of  pain. 
The  causes  of  this  form  of  oculomotor  paralysis  are  not 
known.  Paralysis  of  the  fourth  cranial  nerve  affects 
only  the  superior  oblique  muscle ;  and  of  the  sixth  nerve, 
the  external  rectus. 

Sometimes  the  paralysis  affects  only  certain  associated 
movements.  Thus,  the  vertical  movements  may  be  greatly 
limited,  although  lateral  movements  are  good ;  converg- 
ence may  be  lost,  although  either  internal  rectus  acts 
normally  when  the  eyes  are  both  turned  to  the  right 
or  left ;  or  lateral  movements  may  be  wanting,  although 
the  internal  recti  can  still  converge  the  eyes.  Palsies  of 
this  kind  arise  from  lesions  of  the  nerve-centers  presiding 
over  the  movements  in  question.  They  may  be  some- 
times distinguished  from  peripheral  palsies  by  the  diffi- 
culty or  impossibility  of  fully  fusing  the  double  images 
when  these  are  brought  together  by  prisms.  Paralysis 
of  all  the  external  muscles  of  the  eye,  without  involve- 
ment of  the  iris  or  ciliary  muscle,  is  called  ophthalmoplegia 
externa. 

Symptoms. — Paralysis  of  one  or  more  ocular  muscles 
may  arise  suddenly,  the  patient  awaking  in  the  morning 
to  find  the  affected  muscles  absolutely  powerless.  More 
commonly  the  symptoms  gradually  increase  from  day  to 
day  for  several  days,  or  even  for  some  weeks.  In  the 


206  SYMPTOMS  OF  PARALYTIC  SQUINT. 

latter  case  the  patient  is  conscious  of  gradually  increasing 
difficulty  in  using  the  eyes,  which  passes  into  noticeable 
doubling  of  the  images  at  some  times,  although  at  other 
times  there  is  no  such  difficulty.  The  patient  may  or 
may  not  recognize  that  the  doubling  occurs  only  when  he 
looks  in  a  certain  direction ;  and  can  be  avoided  by  turn- 
ing the  head  instead  of  the  eyes  to  look  in  that  direction, 
or  by  closing  one  eye. 

"  Even  after  diplopia  is  established,  the  feelings  of  con- 
fusion, strain,  giddiness,  and  nausea  continue.  For  in 
one  part  of  the  field  there  remains  normal  single  vision, 
and  between  that  part  and  the  region  of  diplopia  lies  a 
zone,  where  double  vision  is  avoided  only  by  increased 
effort  or  the  closing  of  one  eye.  Closure  of  the  eye  or 
turning  of  the  head  to  prevent  diplopia  becomes  habitual. 
The  ocular  symptoms  may  be  accompanied  by  headache, 
neuralgic  pain  from  involvement  of  the  sensory  nerves, 
or  impairment  of  vision.  Paralysis  of  more  than  one 
muscle  generally  causes  protrusion  of  the  eyeball. 

At  first  the  deviation  and  diplopia  may  be  confined  to 
half  of  the  field  of  fixation  or  less.  After  a  time  the  an- 
tagonist of  the  paralyzed  muscle,  finding  it  no  longer 
meets  with  the  accustomed  resistance,  undergoes  what  is 
called  a  secondary  contraction,  so  that  the  eye,  instead  of 
remaining  properly  directed  when  at  rest,  is  permanently 
turned  from  the  paralyzed  muscle.  This  is  best  illus- 
trated in  the  turning  out  of  the  eye  in  paralysis  of  the 
oculomotor  nerve,  which  involves  all  the  adductors  of  the 
eyeball.  Secondary  contraction  may  not  occur  with  con- 
genital palsies. 

Secondary  deviation  occurs  in  the  sound  eye,  when  it  is 
covered  and  the  affected  eye  attempts  to  fix.  The  weak- 
ened muscles  of  the  affected  eye  are  able  to  fix  it  only  by 
an  effort  in  excess  of  the  normal ;  and  this  excessive 
effort,  extending  to  the  related  muscles  of  the  sound  eye, 
causes  in  it  an  excessive  deviation.  The  secondary  devia- 
tion, being  greater  than  the  primary,  is  sometimes  an 
important  diagnostic  sign  of  paralytic  squint. 

Diagnosis. — The    presence    of   paralytic    squint    is 


DISORDERS  OF  OCULAR  MOVEMENTS.          207 

proved  by  limitation  of  the  movements  of  an  eye,  or  by 
cliplopia  confined  to  one  part  of  the  field  of  vision,  and 
increasing  the  farther  the  eyes  are  turned  in  that  direc- 
tion. In  determining  the  variety  of  the  squint,  and  the 
particular  muscle  affected,  the  first  point  is  to  ascertain 
which  eye  does  not  move  normally.  In  severe  cases  this  is 
readily  ascertained  by  watching  the  motions  of  the  eyes, 
as  they  turn  to  follow  an  object  moved  in  different  direc- 
tions. If  the  deviation  is  slight,  this  will  be  more 
difficult.  If  vision  is  equally  acute  in  both  eyes,  the 
patient  will  incline  to  use  the  unaffected  eye,  fixing 
with  it  and  allowing  the  other  to  deviate.  If,  however, 
vision  is  decidedly  better  in  the  affected  eye,  it  may 
be  used  for  fixation,  and  the  sound  one  will  appear  to 
deviate. 

Which  eye  fixes  is  determined  by  letting  the  patient 
look  at  some  point  in  the  field  of  deviation,  and  then 
intermittently  covering  one  eye.  No  movement  occurs 
if  the  deviating  eye  is  covered ;  but  when  the  fixing  eye 
is  covered,  the  deviating  eye  moves  to  fix.  Often  the 
patient's  impression  is  correct  as  to  which  is  the  false 
image  and  which  the  true  one,  but  not  always. 

The  second  point  in  the  diagnosis  is  to  ascertain  which 
image  belongs  to  the  right  eye  and  which  to  the  left.  This 
may  be  done  by  covering  one  eye  and  asking  which  image 
disappears  ;  but  sometimes  the  patient  is  mistaken  in  his 
answer,  because  if  the  fixing  eye  is  covered,  the  deviating 
eye  may  move  so  quickly  to  fix  the  object  looked  at,  that 
the  corresponding  change  of  its  image  is  unnoticed.  The 
false  image  having  moved  to  take  the  place  of  the  true 
image,  it  is  supposed  that  the  false  image  has  disappeared 
while  the  true  one  has  remained.  By  placing  before  one 
eye  a  piece  of  red  or  blue  glass,  the  patient,  noticing 
which  image  is  colored  red  or  blue,  can  always  decide 
which  image  belongs  to  that  eye. 

The  third  point  is  to  find  what  movements  of  the  eyes 
cause  the  widest  deviation  of  the  affected  eye,  the  widest 
separation  of  the  true  and  false  images.  This  is  done  by 
moving  the  object  looked  at  into  various  parts  of  the  field 


208  DIAGNOSIS  OF  PARALYTIC  SQUINT. 

of  vision,  or  having  the  patient  turn  his  head  in  various 
ways  while  looking  at  a  Axed  object  like  a  lamp-flame. 

The  fourth  point  is  to  ascertain  whether  the  double 
images  remain  parallel  or  incline  toward  each  other  at  the 
top  or  bottom  in  various  parts  of  the  field ;  and  if  they 
are  inclined,  what  the  inclination  is,  and  in  what  part  of 
the  field  it  is  the  greatest.  This  is  done  by  having  a  long 
object,  such  as  a  white  ophthalmoscope  handle  with  a 
dark  background.  This  object  should  be  placed  vertically, 
and  the  patient  asked  if  the  false  image  remains  vertical, 
parallel  to  the  true  image  in  all  parts  of  the  field ;  or,  if 
inclined,  whether  they  are  closer  together  at  the  top  or 
bottom.  The  one  image  remaining  vertical  may  show 
which  eye  it  is  that  deviates. 

Finally,  the  patient  must  observe  whether  the  two 
images  are  on  the  same  level,  or  whether  one  of  them  is 
higher  than  the  other ;  and  which  is  higher,  and  in  what 
part  of  the  field  the  difference  of  level  is  greatest. 

With  these  five  points  determined  it  is  easy  to  decide 
which  muscle  or  movement  is  affected.  For  the  paralysis 
of  a  single  muscle  the  first  point  is  the  only  one  which 
offers  much  difficulty ;  and  that  only  when  the  deviation 
is  slight.  When,  however,  several  muscles  are  paralyzed, 
the  problem  of  analyzing  the  diplopia  becomes  so  complex 
that  sometimes  nothing,  except  observation  of  actual  fail- 
ure of  the  eyeball  to  make  certain  movements,  can  be 
relied  on  to  fix  the  location  of  the  paralysis. 

Paralysis  of  the  external  rectus  limits  movement  of 
the  eye  to\vard  the  affected  side.  If  the  right  eye  be  in- 
volved, it  cannot  be  turned  to  the  right ;  if  the  left  eye, 
it  cannot  be  turned  to  the  left.  It  causes  a  convergent 
squint  which  increases  as  the  eyes  are  turned  toward  the 
affected  side.  The  diplopia  is  homonymous,  the  images 
separating  as  the  eyes  turn  toward  the  affected  side.  The 
images  are  the  same  height  and  parallel,  or  slightly  tilted 
wrhen  looking  down  or  up. 

Paralysis  of  the  superior  rectus  limits  movement  up- 
ward, the  deviation  and  distance  between  the  images 
increasing  in  that  direction.  The  false  image  is  the 


DISORDERS  OF  OCULAR  MOVEMENTS.          209 

higher,  and  toward  the  sound  side  (crossed  diplopia)  the 
images  are  nearly  parallel  when  the  eyes  are  turned 
toward  the  affected  side ;  but  the  false  image  is  tilted,  its 
top  from  the  true  image,  when  the  eyes  are  converged  or 
turned  toward  the  sound  side. 

Paralysis  of  the  Internal  Rectus. — The  eye  tends  to 
deviate  outward  (divergent  squint),  the  deviation  increas- 
ing as  the  eyes  are  converged  or  turned  toward  the  sound 
side.  The  diplopia  is  crossed,  the  images  separating  as 
the  eyes  are  turned  toward  the  sound  side.  The  images 
are  about  on  a  level  and  parallel,  unless  the  eyes  are 
turned  strongly  up  or  down,  when  some  tilting  occurs. 

Paralysis  of  the  inferior  rectus  limits  the  movement 
of  the  affected  eye  downward,  and  the  distance  between 
the  images  increases  on  looking  down.  The  false  image, 
is  the  lower,  and  is  toward  the  sound  side  (crossed  diplo- 
pia). The  images  are  parallel  when  the  affected  eye  is 
turned  somewhat  out  (looks  toward  the  affected  side)  ;  but 
the  false  image  is  tilted,  top  toward  the  true  image,  when 
the  affected  eye  is  turned  in  (looks  toward  the  sound  side). 

Paralysis  of  the  superior  oblique  limits  movement 
downward  and  outward,  and  the  images  separate  most 
widely  in  this  direction.  The  false  image  is  toward  the 
affected  side  (homonymous  diplopia),  and  is  most  tilted 
when  the  eyes  are  turned  toward  the  affected  side.  When 
the  eyes  are  turned  toward  the  sound  side,  the  images  are 
about  parallel,  and  the  false  image  decidedly  the  lower. 

Inferior  oblique  paralysis  causes  limitation  of  the 
movements  upward  and  outward,  and  the  images  separate 
most  widely  in  those  directions.  The  false  image  is 
toward  the  affected  side  (homonymous  diplopia)  and 
higher.  It  is  most  tilted  on  looking  toward  the  affected 
side,  the  top  from  the  true  image,  and  is  about  parallel 
and  most  elevated  on  looking  toward  the  sound  side. 

In  Figs.  77  to  82,  inclusive,  the  black  bars  mark  the 
part  of  the  field  in  which  there  is  single  vision ;  the  bars 
with  the  lines  running  up  to  the  right  indicate  the  image 
belonging  to  the  right  eye ;  and  those  with  lines  running 
up  and  to  the  left,  the  image  belonging  to  the  left  eye. 

14 


210 


DIAGNOSIS  OF  PARALYTIC  SQUINT. 


The  bars  which  are  darkly  shaded  represent  the  true 
image,  and  those  which  are  lightly  shaded  the  false  image. 


i  B 
I  I 
i  B 

I 
\ 

\ 
I 
I 

1 
1 
1 

1 
1 

1  1 
i  i 
I  1 

Left.  Right. 

FIG.  77.—  Paralysis  of  external  rectus. 


1     1     1 

1     1     1 

Left.  Right. 

FIG.  78.— Paralysis  of  superior  rectus. 


III 

s\  fi  1 

1   1   1 

D      ^ 

Left.  Right. 

FIG.  79. — Paralysis  of  superior  oblique. 


Differential  Diagnosis. — Homonymous  diplopia 
— convergent  squint — occurs  in  paralyses  of  the  ocular 
muscles,  which  are  thus  differentiated  : 


DISORDERS  OF  OCULAR  MOVEMENTS. 


211 


I     I 


I     I 


I     I 


I     I 


Left.  Right. 

FIG.  80.— Paralysis  of  internal  rectus. 


I      I      I 


I      I      I 


I      I      I 


Left.  Right. 

FIG.  81.— Paralysis  of  inferior  oblique. 


I      I      I 


Left.  Right. 

FIG.  82.— Paralysis  of  inferior  rectus. 

External  Rectus. — Images  the  same  height  and  parallel. 
They  separate  most  widely  on  looking  toward  the  affected 
side. 

Superior  Oblique. — Images  separate  on  looking  down, 
the  false  image  tilted  on  looking  toward  the  aifected  side, 
displaced  downward  on  looking  toward  the  sound  side. 

Inferior  Oblique. — Images  separate  on  looking  up,  the 


212  DIAGNOSIS  OF  PARALYTIC  SQUINT. 

false  image  tilted  on  looking  toward  the  affected  side, 
displaced  upward  on  looking  toward  the  sound  side. 

Crossed  diplopia — divergent  squint — attends  three 
palsies : 

Internal  Rectus. — Images  of  the  same  height  and  par- 
allel. They  separate  most  on  looking  toward  the  sound 
side. 

Superior  Rectus. — Images  separate  on  looking  up,  par- 
allel toward  the  affected  side ;  tilted  with  the  tops  apart 
on  looking  toward  the  sound  side,  the  false  image  higher. 

Inferior  Rectus. — Images  separate  most  on  looking 
down,  are  parallel  when  looking  toward  the  affected  side  ; 
and  tilted,  tops  together,  in  looking  toward  the  sound  side, 
false  image  lower. 

Treatment. — In  the  early  stages  this  will  depend 
upon  the  cause.  A  palsy  from  traumatism  will  require 
rest.  If  the  history  points  toward  syphilis,  potassium 
iodid  or  the  mixed  iodids,  in  doses  rapidly  ascending  to 
the  maximum,  will  be  indicated.  These  should  be  con- 
tinued for  at  least  two  months,  unless  recovery  is  complete 
before  that.  Even  if  there  be  no  history  of  syphilis,  but 
the  etiology  is  obscure,  the  same  treatment  is  admissible. 
If  there  is  rheumatism,  or  a  history  of  "cold,"  sodium 
salicylate  may  be  given  in  full  doses  for  two  or  three  days, 
or  sometimes  longer ;  then  the  iodids  may  be  resorted  to, 
and  continued  for  several  weeks.  At  the  very  outset, 
cases  of  this  kind  may  be  favorably  influenced  by  a  hot 
bath,  or  a  pilocarpin  sweat. 

When  the  paralysis  is  due  to  diphtheria,  or  chronic 
poisoning,  or  arises  in  connection  with  degenerative  dis- 
ease of  the  central  nervous  system,  the  treatment  should 
from  the  start  include  general  tonics  and  strychnin  in 
ascending  doses,  until  decided  improvement  occurs,  or  the 
maximum  physiological  dose  has  been  reached  and  kept 
up  for  several  weeks.  In  cases  of  this  kind,  change  of 
residence,  occupation,  or  manner  of  living  may  be  im- 
portant. These  measures  may  be  beneficial  in  the  later 
stages  of  paralysis  from  all  causes. 

When  the  paralysis  has  continued  two  or  three  weeks, 


DISORDERS  OF  OCULAR  MOVEMENTS.          213 

electricity  may  be  tried,  the  positive  pole  being  placed  as 
closely  as  possible  over  the  affected  muscle,  and  the  nega- 
tive behind  the  ear  or  on  the  back  of  the  neck.  When 
the  paralysis  has  continued  many  weeks,  and  seems 
stationary,  muscle-stretching  may  be  resorted  to.  Under 
cocain  the  insertion  of  the  tendon  of  the  muscle  is  seized 
with,  fixation-forceps,  and  the  eye  slowly  and  forcibly 
rotated  to  and  fro  so  as  alternately  to  stretch  and  relax 
the  paralyzed  muscle.  The  rotation  both  ways  is  repeated 
ten  or  twelve  times  a  minute  for  two  or  three  minutes,  at 
each  sitting ;  and  the  sittings  repeated  every  two  or  three 
days.  The  manipulation  must  not  be  so  violent  as  to 
cause  serious  subsequent  soreness,  yet  the  paralyzed  mus- 
cle and  its  antagonist  should  be  decidedly  stretched. 

When  the  case  has  become  chronic,  and  the  extent  of 
the  squint  fixed  (or  in  cases  of  moderate  paresis  from  an 
earlier  period),  prisms  may  afford  relief.  The  base  of  the 
prism  before  the  affected  eye  should  be  turned  toward  the 
weakened  muscle,  and  the  prism  before  the  sound  eye 
correspondingly  placed.  Prisms  thus  placed  render  pos- 
sible binocular  single  vision,  while  the  eye  deviates 
toward  the  apex.  Prisms  thus  worn  must  be  watched, 
and  the  strength  varied  according  to  the  changes  in  the 
deviation.  Prisms  may  also  be  used  turned  the  opposite 
way  (with  the  apex  toward  the  weakened  muscle),  to 
compel  its  more  powerful  exertion,  and  thus  to  develop 
its  strength.  For  this  purpose  they  are  to  be  used  only  a 
few  minutes  at  a  time,  one  or  more  times  a  day. 

A  better  method  of  giving  the  weakened  muscle  gym- 
nastic exercise  and  training  is  to  have  the  patient  fix 
both  eyes  upon  a  small  object  held  in  the  portion  of  the 
field  of  vision  where  there  is  no  diplopia,  and  then  slowly 
moving  the  object  over  into  the  field  of  diplopia,  keep  it 
single  as  long  as  possible.  As  soon  as  diplopia  occurs  in 
spite  of  a  strong  effort,  the  effort  is  to  be  suspended,  and 
the  eyes  are  to  be  allowed  to  rest  for  a  minute  or  so. 
Then  the  exercise  may  be  repeated.  Each  effort  should 
occupy  ten  or  fifteen  seconds,  and  it  may  be  repeated 
several  times  at  a  sitting,  with  several  sittings  a  day.  In 


214  TREATMENT  OF  OCULAR  PALSIES. 

the  earlier  trials  care  should  be  taken  not  to  overstrain 
the  weakened  muscle. 

To  escape  the  vertigo  and  annoying  diplopia,  while 
these  continue,  the  deviating  eye  may  be  covered  by  a 
ground  glass,  or  by  a  piece  of  tissue  paper,  pasted  on  the 
back  of  the  patient's  ordinary  spectacles.  Sometimes  it 
is  better  to  shut  off  in  this  way  only  the  part  of  the  field 
of  vision  in  which  diplopia  or  confusion  of  sight  occurs, 
leaving  the  eye  free  for  binocular  vision  in  the  other  parts 
of  the  field. 

When  paralytic  squint  has  become  partly  com itant, 
the  operative  treatment  of  the  latter  may  be  applicable ; 
and  even  if  the  squint  be  still  chiefly  paralytic,  the 
patient  can  in  a  few  cases  be  given  decided  help  by  an 
advancement  of  the  affected  muscle,  or  a  tenotomy  of  its 
antagonist,  or  both.  This  will  be  the  case  wrhen  by 
operation  it  will  be  possible  to  remove  the  field  of  diplopia 
from  directly  in  front,  or  from  the  direction  in  which  the 
patient  wishes  to  use  his  eyes  habitually,  to  some  other 
part  of  the  field  of  vision.  Sometimes  an  operation  may 
be  done  for  cosmetic  reasons. 

Prognosis. — Paralytic  squint,  seen  early  and  appro- 
priately treated,  is  cured  in  a  large  proportion  of  cases. 
If  due  to  syphilis  or  rheumatism,  at  least  partial  recovery 
may  be  expected.  Diphtheritic  paralysis  of  the  ocular 
muscles  does  not  show  the  same  strong  tendency  to  com- 
plete recovery  shown  by  other  diphtheritic  palsies, 
although  its  prognosis  is  favorable.  Nuclear  palsies, 
coming  early  in  degenerative  disease  of  the  central  nerv- 
ous system,  are  especially  variable  in  the  degree  of  dis- 
ability they  cause ;  they  sometimes  go  on  to  practically 
complete  recovery,  although  the  general  disease  continues 
to  advance.  Partial  recovery  from  paralysis  of  the 
external  rectus,  or  superior  oblique,  leaves  the  patient 
without  noticeable  deformity,  and  often  still  able  to  use 
the  eyes  freely  without  diplopia  or  serious  inconvenience. 
But  permanent  partial  paralysis  of  the  oculomotor  nerve 
is  mostly  accompanied  with  marked  divergence  of  the 
eyeball,  and  limitation  of  its  movements,  drooping  of  the 


DISORDERS  OF  OCULAR  MOVEMENTS.          215 

lid,  diplopia  on  raising  the  lid,  and  inability  to  use  the 
affected  eye.  In  recurrent  oculomotor  paralysis  the 
recoveries  from  successive  attacks  become  more  and  more 
incomplete,  until  complete  disability  of  the  affected  mus- 
cles becomes  permanent.  The  diplopia  of  paralytic  squint 
continues,  and  gives  annoyance  so  long  as  the  deviation 
lasts. 

COMITANT  SQUINT. 

The  same  deviation  occurring  in  all  parts  of  the  visual 
field,  is  the  characteristic  of  comitant.  squint.  It  may 
not  be  the  same  at  different  times,  it  may  part  of  the  time 
be  entirely  absent,  but  when  present  it  is  not  confined  to, 
or  greater  in,  one  part  of  the  visual  field  than  another. 

Since  both  eyes  do  not  turn  toward  the  same  point,  it 
is  evident  that  only  one  can  "  fix,"  and  the  other  one 
must  "  deviate."  Habitually  the  patient  inclines  to  use 
his  better  eye,  if  there  is  even  a  slight  difference  between 
them,  and  the  eye  with  the  poorer  vision  is  allowed  to 
deviate.  But  it  must  not  be  thought  on  that  account  that 
the  squint  belongs  in  any  peculiar  way  to  that  eye,  rather 
than  to  the  other.  True  comitant  squint  is  a  false  co- 
ordination of  the  two  eyes ;  it  is  a  disorder  of  their  rela- 
tion. Either  eye  alone  is  absolutely  normal,  one  just  as 
normal  in  its  movements  as  the  other;  you  must  have 
two  eyes  to  have  a  squint. 

Causes. — Typical  paralytic  and  comitant  squint  have 
thus  far  been  considered,  but  many  cases  occur  of 
mixed  type.  When  secondary  contraction  of  its  antagon- 
ist has  occurred,  recovery  of  power  in  a  paralyzed  muscle 
gives  rise  to  a  comitant  .squint.  With  full  recovery 
of  power,  secondary  contraction  may  be  overcome  and  the 
squint  disappear ;  but  in  the  presence  of  other  conditions 
that  tend  to  cause  squint,  in  spite  of  the  full  recovery  of 
the  paralyzed  muscle  or  muscles,  the  squint  continues. 
This  is  probably  the  mode  of  origin  of  a  considerable 
proportion  of  cases  of  comitant  squint. 

Binocular  vision,  and  the  accurate  co-ordination  of  the 
movements  of  the  two  eyes  are  functions  almost  or  quite 


216  CAUSES  OF  COMITANT  SQUINT. 

peculiar  to  man.  They  are  mutually  dependent.  While 
binocular  vision  is  impossible  without  the  accurate  co- 
ordination of  the  movement  of  the  two  eyes,  such  accurate 
co-ordination  is  usually  impossible  except  under  the 
guidance  of  binocular  vision.  The  two  develop  together, 
usually  during  the  first-  weeks  or  months  after  birth,  but 
sometimes  they  are  not  perfected  until  the  child  is  several 
years  old.  During  the  period  of  their  incomplete  develop- 
ment they  are  most  easily  prevented  or  overthrown. 
Hence,  most  cases  of  comitant  squint  arise  in  early  child- 
hood. 

Removal  of  the  guidance  of  binocular  vision  is  likely 
to  impair  the  binocular  co-ordination  of  movement  at  any 
age.  Hence,  complete  blindness  of  either  eye  is  likely  to 
cause  squint.  Great  impairment  of  vision  from  corneal 
injury  or  disease,  which  causes  distortion  or  blurring  of 
the  retinal  images  by  the  admission  of  diifuse  light,  is 
likely  to  cause  squint.  On  the  other  hand,  very  imperfect 
vision  with  normal  retinal  images  may  furnish  the  neces- 
sary guidance  to  binocular  adjustment.  Congenital  defects 
of  the  retina  at  the  fixation-point,  or  of  the  optic  tracts  or 
centers  causing  central  scotoma,  are  likely  to  cause  squint; 
but  injury  of  these  parts  by  disease,  after  binocular  move- 
ments are  well  established,  will  not  cause  it. 

It  is  probable  that  in  a  few  cases  anomalies  in  the 
attachments  or  strength  of  the  ocular  muscles  tend  to 
cause  squint.  But  the  enormous  adaptability  these  muscles 
show  when  the  eyeball  is  displaced  by  tumor,  or  after 
their  mutilation  by  ill-advised  operations  for  heterophoria, 
makes  it  improbable  that  such  mechanical  influences  as 
are  exerted  by  a  certain  general  shape  of  orbit,  or  width 
between  the  orbits,  play  any  important  part  in  causing 
squint.  The  very  intimate  association  of  errors  of  refrac- 
tion with  certain  kinds  of  squint  is  dealt  with  in  connec- 
tion with  these  special  varieties. 

Varieties. — Constant  squint,  as  its  name  implies,  is 
always  present,  but  it  may  from  time  to  time  vary  greatly 
in  degree.  If  the  squint  be  part  of  the  time  entirely 
absent,  it  is  called  intermittent  or  periodic  squint,  but  it 


DISORDERS  OF  OCULAR  MOVEMENTS.          217 

presents  no  strictly  regular  periodicity.  Accommodative  is 
a  form  of  intermittent  squint  that  appears  only  when  the 
accommodation  is  strongly  exerted.  When  one  eye  habit- 
ually fixes  and  the  other  habitually  deviates,  the  squint 
is  called  monolateral  or  monocular.  If  both  eyes  see 
equally  well  and  with  the  same  effort,  sometimes  one  will 
fix,  and  sometimes  the  other.  This  is  called  alternating 
squint.  Even  when  there  is  a  slight  difference  between 
the  eyes,  the  squint  may  be  at  first  alternating.  It  may 
also  alternate  when  the  refraction  of  one  eye  adapts  it  to 
distant  vision,  while  that  of  the  other  fits  it  only  for  near- 
seeing. 

Squint  occurring  as  a  form  or  part  of  a  convulsive 
seizure  may  be  called  convulsive  squint.  Closely  allied  to 
it  is  squint  occurring  as  a  manifestation  of  hysteria, 
hysterical  .squint  (see  Spastic  Squint). 

Convergent  squint  is  the  commonest,  variety.  The 
visual  axes  are  at  all  times  converged.  On  looking  at 
distant  objects  they  converge  least ;  on  looking  at  near 
objects  they  converge  more  strongly.  At  all  times  the 
convergence  is  excessive,  the  visual  lines  intersecting 
nearer  to  the  eye  than  the  point  fixed.  In  the  popular 
mind  this  variety  has  long  been  associated  with  the  efforts 
of  young  children  to  look  at  objects  held  too  close  to  the 
eyes.  It  is  usually  established  before  the  age  of  six  years. 

Donders  pointed  out  that  it  had  a  connection  with  hyper- 
opia.  Hyperopia  requires  excessive  exertion  of  accom- 
modation. Accommodation  is  closely  associated  with 
convergence,  therefore  hyperopia  tends  to  produce  ex- 
cessive convergence.  But  every  pair  of  convex  or  con- 
cave lenses  worn  affects  the  amount  of  accommodation 
exerted,  yet  usually  the  permanent  influence  they  exert 
on  the  convergence  of  the  eyes  is  insignificant,  so  that 
the  necessary  influence  of  hyperopia  in  causing  conver- 
gent squint  is  for  many  cases  slight.  Then,  since  70  per 
cent,  of  all  persons  are  hyperopic,  mere  coincidence  would 
account  for  the  hyperopia  in  that  proportion  of  the  cases 
of  convergent  squint. 

But  there  is  a  frequency  of  association  between  con- 


218  CONVERGENT  SQUINT. 

vergent  squint  and  hyperopia  of  high  degree,  3.  to  6.  D., 
that  coincidence  does  not  explain.  These  cases  of  squint 
are  usually  intermittent,  or  if  constant  are  quite  variable 
in  degree.  The  squint  increases  greatly  when  the  eyes 
are  used  for  accurate  seeing,  especially  for  near  vision. 
Other  causes  of  squint,  as  imperfect  vision,  or  a  previous 
ocular  paralysis,  are  mostly  absent  from  these  cases,  and 
correction  of  the  hyperopia  cures  the  squint.  Such  cases  of 
squint  seem  clearly  due  to  an  overflow  of  nervous  impulse, 
which  affects  the  convergence  from  the  excessive  effort 
of  accommodation. 

Divergent  squint  is  a  condition  of  relatively  deficient 
convergence.  On  looking  at  a  distant  object  the  visual 
lines  may  diverge,  on  looking  at  a  near  object  they  may 
become  parallel  or  even  convergent,  but  they  never  con- 
verge enough  to  meet  at  the  object  looked  at.  Aside 
from  blindness  and  previous  oculomotor  paralysis,  diver- 
gent squint  usually  arises  in  connection  with  myopia  ;  and 
since  myopia  is  usually  acquired,  it  comes  on  later  in  life 
than  convergent  squint. 

The  myopic  eye,  having  to  accommodate  but  relatively 
little,  loses  whatever  stimulus  accommodation  may  give 
to  aid  convergence.  Far  more  important  factors,  how- 
ever, in  the  causation  of  divergent  squint  are  found  in 
the  excessive  amount  of  convergence  required  by  myopic 
eyes,  and  the  excessive  difficulties  of  convergence  on 
account  of  the  elongation  of  the  eyeball  already  re- 
ferred to  (p.  159).  These  conditions  also  constitute  the 
most  serious  obstacles  to  the  correction  of  this  form  of 
squint. 

Divergent  squint  usually  begins  by  simply  allowing 
the  worse  eye  to  diverge  relatively,  when  very  near 
objects  are  looked  at,  while  at  other  times  its  direction  is 
normal.  At  first  the  squint  is  intermittent,  merely  a 
failure  to  converge  strongly,  when  strong  convergence  is 
required  to  fix  the  object.  But  when  once  this  habit  is 
established,  the  deviation  is  liable  to  become  more  fre- 
quent and  greater,  until  the  squint  occurs  at  all  distances, 
and  becomes  constant.  Alternating  divergent  squint  is 


DISORDERS  OF  OCULAR  MOVEMENTS.          219 

rare,  since  in  high  myopia  one  eye  usually  has  decidedly 
better  vision  than  the  other. 

Vertical  squint  is  the  deviation  of  one  eye  upward  or 
downward,  so  that  its  visual  line  no  longer  lies  in  the 
visual  plane — the  plane  passed  through  the  centers  of 
rotation  of  the  two  eyes,  and  the  point  on  which  the  gaze 
is  fixed.  It  occurs  separately,  either  from  traumatism  or 
as  a  sequel  to  a  paralytic  squint,  but  it  occurs  far  more 
frequently  in  connection  with  convergent  or  divergent 
squint.  Indeed,  marked  lateral  deviation  is  usually 
accompanied  by  some  departure  of  the  visual  line  of  the 
deviating  eye  from  the  visual  plane.  Such  deviation  is 
more  frequently  upward  than  downward. 

Symptoms. — Comitant  squint  generally  first  attracts 
attention  by  the  appearance  of  the  deviating  eye.  The 
deviation  is  usually  greater  at  some  times  than  others. 
In  some  cases  it  is  most  noticeable  when  the  patient  is 
tired,  in  others  when  excited  or  angry.  The  patient  may 
think  it  intermittent,  when  in  reality  it  is  only  variable. 
The  patient  is  not  likely  to  underrate  the  importance  of  a 
visible  squint ;  but  parents  and  friends,  who  have  become 
accustomed  to  the  deformity,  often  fail  to  realize  the 
suifering  and  disadvantage  of  such  deformity  to  a  young 
person. 

Diplopia  is  rarely  complained  of,  and  in  some  cases  it 
cannot  be  produced.  It  is  most  likely  to  cause  annoy- 
ance in  squint  developed  in  adult  life.  Comitant  squint 
is  not  likely  to  cause  symptoms  of  eye-strain,  except 
in  those  cases  in  which  the  squint  is  intermittent,  and 
gives  rise  to  such  serious  diplopia  that  the  patient  by 
a  special  effort  prevents  the  squint  or  renders  it  latent  a 
part  of  the  time,  to  avoid  the  diplopia.  Of  the  impaired 
judgment  as  to  distances,  lessened  field  of  vision,  or  other 
disabilities  caused  by  the  lack  of  binocular  vision,  the 
patient  is  not  usually  conscious.  The  connection  of  am- 
blyopia  with  squint  has  been  sufficiently  discussed 
(p.  198). 

Diagnosis. — To  determine  whether  squint  is  real  or 
apparent,  the  test  of  alternately  covering  the  eyes  (see  p. 


220  DIAGNOSIS  OF  CO  MIT  A  NT  SQUINT. 

199)  is  to  be  used.  This  will  also,  by  the  extent  of  the 
secondary  deviation,  indicate  whether  the  squint  is  par- 
alytic, or  partly  of  that  character.  If  the  squint  is 
monolateral,  the  fixing  eye  will  immediately  return  to 
fixation  as  soon  as  it  is  uncovered,  and  the  deviation 
return  to  the  other  eye.  If  the  squint  be  alternating, 
either  eye,  when  made  to  fix,  will  continue  to  fix  when 
both  eyes  have  been  uncovered.  The  amount  of  squint 
should  be  measured  (see  p.  201)  repeatedly,  at  different 
times  and  under  different  circumstances. 

If  the  deviating  eye  has  useful  vision,  a  careful  attempt 
should  be  made  to  secure  binocular  diplopia.  The  fixing 
eye  being  covered,  the  deviating  eye  is  made  to  fix  a 
lamp-flame  in  the  darkened  room.  Then  the  fixing  eye 
is  allowed  to  look  through  colored  glass,  so  dark  as  to 
lower  its  acuteness  of  vision  even  below  that  of  the  de- 
viating eye.  Repeated  trials  may  be  required  before  the 
false  image  is  recognized,  but  practice  renders  the  recog- 
nition easier  and  more  certain.  Sometimes  a  strong 
prism,  so  placed  as  to  bring  the  false  image  nearer  to 
the  macula,  aids  greatly  in  its  recognition.  The  fusion 
tubes  of  Priestley  Smith  furnish  a  useful  means  of  recog- 
nizing diplopia,  and  training  the  patient  to  overcome  it. 
They  consist  of  two  short  cylinders,  each  with  a  convex 
lens  in  one  end,  and  a  cap  with  a  hole  in  it  at  the  other. 
The  tubes  are  freely  movable  with  reference  to  each  other. 
If  both  holes  are  seen  at  once,  we  have  evidence  of 
diplopia,  and  by  turning  the  tubes  so  as  to  fuse  the  images 
of  the  two  openings,  we  can  ascertain  the  directions  taken 
by  the  visual  axes. 

When  binocular  diplopia  has  been  secured,  an  effort 
should  be  made  to  bring  the  true  and  false  images  together 
with  prisms.  These  are  to  be  turned  with  their  edges  in 
the  direction  in  which  the  eye  deviates.  If  the  images 
when  brought  together  with  prisms  can  be  fused,  giving 
binocular  vision,  complete  cure  by  operation  may  be  pos- 
sible. If,  however,  the  images  when  brought  together 
refuse  to  become  one,  falling  short  of  eaeli  other  with  one 
prism,  and  then  jumping  past  each  other  when  the  strength 


DISORDERS  OF  OCULAR  MOVEMENTS.          221 

of  the  prism  is  slightly  increased ;  and  if  this  refusal  is 
persisted  in  at  repeated  trials,  the  case  is  one  not  capable 
of  complete  cure,  and  the  more  accurately  the  deviation 
is  corrected  the  more  annoying  the  diplopia  may  be 
made.  Other  points  in  diagnosis  have  already  been 
sufficiently  discussed. 

Treatment. — Many  cases  of  squint  are  capable  of 
cure,  at  an  early  stage,  without  operation.  If  both  eyes 
have  useful  vision,  the  first  step  should  be  careful  correc- 
tion of  errors  of  refraction,  and  the  constant  wearing  of 
correcting  lenses.  This  will  at  an  early  stage  cure  all 
cases  of  squint  due  to  hyperopia.  Even  though  the  squint 
be  of  several  years'  standing,  if  it  be  intermittent,  or  if 
at  times  it  becomes  very  slight,  if  the  hyperopia  be  of 
high  degree,  the  full  correction  constantly  worn  is  likely 
to  cure  it.  If  the  hyperopia  be  moderate  or  high,  the 
correcting  lenses  should  be  worn  for  a  time,  preferably  for 
several  months  before  undertaking  an  operation.  Espe- 
cially if  the  deviation  is  variable  or  only  moderate,  should 
the  lenses  first  have  a  prolonged  trial. 

In  divergent  squint  connected  with  myopia,  if  the 
patient's  vision  be  good  enough  to  enable  him  to  read  and 
work  at  the  ordinary  distance,  and  if  the  squint  be  still  in- 
termittent, the  lenses  may  cure  the  squint.  Their  effect  in 
promoting  binocular  vision  may  be  increased  by  decenter- 
ing.  Often  the  most  important  influence  of  correcting 
lenses  is  in  correcting  the  inequalities  between  the  two  eyes, 
bringing  up  the  defective  vision  of  one  eye,  or  so  equaliz- 
ing the  effort  of  accommodation  that  the  two  eyes  can 
work  together.  The  lessening  of  the  obstacles  to  binocular 
vision  may  be  the  essential  point,  without  which  all  other 
measures  will  prove  insufficient  to  bring  about  a  cure. 

Squint  beginning  generally  in  early  childhood,  it  often 
becomes  an  important  question  at  what  age  should  chil- 
dren begin  wearing  glasses.  Since  so  much  more  is  to 
be  hoped  for  in  the  way  of  development  of  binocular  co- 
ordination in  the  earlier  years,  it  is  important  that  the 
wearing  of  glasses  should  be  commenced  as  soon  as  pos- 
sible if  they  are  clearly  needed.  The  writer  has  pre- 


222  TREATMENT  OF  COMITANT  SQUINT. 

scribed  glasses,  determined  by  skiascopy,  before  the  age 
of  three  years  with  the  greatest  benefit.  When  they  are 
much  needed,  as  in  high  hyperopia,  it  is  often  easy  to  get 
a  very  young  child  to  wear  them.  They  should  first  be 
worn  while  the  eyes  are  under  a  cycloplegic,  when  they 
will  greatly  improve  vision,  and  after  a  few  days  they 
will  be  accepted  without  the  continuance  of  the  drug. 

Sometimes  a  cycloplegic  is  used  to  keep  the  squint  from 
becoming  fixed  before  the  glasses  can  be  worn.  It  may 
be  used  either  in  both  eyes  to  prevent  accommodative 
efforts,  or  in  the  fixing  eye  alone,  to  blur  its  vision  and 
induce  the  patient  to  employ  the  deviating  eye  and  so 
avoid  the  habit  of  neglecting  it. 

If  the  constant  wearing  of  correcting  lenses  for  several 
months  leaves  a  constant  squint,  or  if  the  squint  be  of 
high  degree  and  the  error  of  refraction  trifling,  and  there 
is  little  to  be  gained  in  the  way  of  enabling  the  two  eyes 
to  work  together,  if  the  patient  is  of  proper  age,  an 
operation  is  to  be  advised.  The  proper  age  for  a  squint 
operation  may  be  set  at  the  earliest  age  at  which  a  com- 
plete study  of  the  case  can  be  made ;  and  it  can  certainly 
be  known  that  the  squint  is  not  merely  an  incomplete  or 
delayed  development  of  binocular  co-ordination,  but  is 
truly  comitant,  with  the  amount  of  deviation  fairly 
constant,  and  that  the  wearing  of  glasses  will  fail  to  cure 
it.  While  no  strict  age-limit  can  be  fixed,  it  is  rarely 
that  a  squint  should  be  corrected  by  operation  before  the 
age  of  five  or  six  years.  Low  degrees,  especially  if 
variable,  should  not  be  operated  on  until  after  puberty, 
unless  there  is  easily  produceable  diplopia  with  good 
capacity  for  complete  fusion  of  the  images. 

Intermittent  squint  should  not  be  operated  for  at  any 
age,  unless  it  is  found  that  when  the  squint  seems  absent 
it  is  merely  latent  or  suppressed. 

The  operations  for  squint  are  tenotomi/  of  the  muscle 
which  seems  to  turn  the  eye  too  strongly  in  its  direction, 
or  advancement  of  the  muscle  which  does  not  exert  suffi- 
cient influence  on  the  movements  of  the  eyeball,  or  both 
conjoined.  Thus,  for  convergent  squint  one  may  do  ten- 


DISORDERS  OF  OCULAR  MOVEMENTS.          223 

otomy  of  the  internal  rectus,  or  advancement  of  the  exter- 
nal rectus,  or  both.  In  a  purely  comitant  squint  the 
operations  may  be  done  on  the  muscle  of  either  eye.  If 
a  marked  deviation  is  to  be  corrected,  the  best  result  is  to 
be  obtained  by  dividing  the  readjustment  between  the  two. 
If,  however,  the  correction  is  to  be  made  by  a  single 
operation,  it  is  better  to  do  this  on  the  deviating  eye, 
because  the  poorer  eye  should  bear  the  slight  risks  that 
attend  even  such  an  operation. 

The  effect  of  the  same  operation  is  very  different  in 
different  cases,  but  usually  a  simple  tenotomy  may  be 
expected  to  correct  from  15  to  25  centrads  of  deviation. 
A  smaller  deviation  may  be  corrected  by  advancement 
alone  ;  a  greater  deviation  by  advancement  with  tenotomy 
of  the  opposing  muscle.  Sometimes  the  effect  of  a  tenotomy 
may  be  considerably  increased  by  passing  a  thread  through 
the  insertion  of  the  divided  muscle,  carrying  it  toward 
the  opposite  canthus  and  fastening  it  over  a  roll  of  adhe- 
sive plaster.  If  the  effect  produced  is  excessive,  the 
divided  muscle  may  be  drawn  forward  toward  its  inser- 
tion by  a  stitch  ;  or  an  advanced  muscle  permitted  to  slip 
back,  by  inserting  another  loose  stitch  and  cutting  the  one 
which  drew  upon  it  too  strongly.  It  is  best,  as  a  rule,  to 
aim  at  a  slight  under-correction  (5  to  3  degrees)  of 
convergent  squint ;  and  rather  an  over-correction  of 
divergent  squint.  The  operations  are  described  in  detail 
in  Chapter  XIX. 

When  the  deviation  is  quite  variable  in  amount,  or 
when  it  seems  to  depend  on  delayed  development  of 
binocular  co-ordination,  and  after  the  breaking  up  of 
habits  of  ocular  movement  that  an  operation  causes,  the 
educative  treatment  may  be  of  value.  Simple  enforced 
use  of  the  deviating  eye,  by  covering  the  fixing  eye,  is  a 
good  preparation  in  monolateral  squint  for  operation  and 
for  post-operative  training.  A  very  practical  measure 
is  that  of  reading  with  a  reading  bar  or  a  ruler  held  in 
front  of  the  page  in  such  a  way  that  each  eye  can  see 
only  a  part  of  the  page,  and  both  eyes  must  be  used  to 
read  the  whole  of  each  line.  With  young  children  this 


224  EDUCATIVE  TREATMENT. 

may  be  replaced  by  a  beak  of  cardboard  or  metal  fastened 
to  a  band  around  the  head,  which  supports  it  in  a  similar 
position.  Exercise  with  the  fusion  tubes  may  also  be 
useful.  Partial  pictures  may  be  placed  in  the  two  sides 
of  a  stereoscope,  the  complete  image  to  be  obtained  only 
by  combining  them.  After  operation  the  patient  may 
place  an  object  in  the  portion  of  the  field  where  its  images 
are  most  easily  fused,  and  then  slowly  move  it  toward  the 
part  of  the  field  where  their  fusion  is  more  difficult,  or 
prisms  may  be  used  to  assist  in  fusion.  These  measures 
are  applicable  only  where  binocular  diplopia  can  be 
evoked,  and  the  two  images  are  capable  of  fusion. 

Prisms  do  not  correct  squint;  but  turned  with  their 
edges  in  the  direction  of  deviation,  they  aid  in  procuring 
binocular  vision  in  spite  of  the  deviation.  On  account 
of  the  extent  of  the  deviation  to  be  overcome,  they  are 
of  no  practical  value  in  convergent  squint;  but  where 
strong  lenses  must  be  worn  for  high  myopia,  they  may 
help  in  cases  of  divergent  squint.  They  are  of  most  use 
in  cases  of  vertical  squint,  since  these  present  slighter 
deviations;  and  stronger  prisms  may  be  worn,  with  the 
base  turned  up  or  down. 

Squint  occurring  in  early  childhood  sometimes  disap- 
pears by  farther  development  of  the  power  of  co-ordina- 
tion. This  fact,  although  a  sound  reason  for  deferring 
operation  until  other  means  have  been  tried,  is  a  most 
powerful  argument  for  the  earliest  possible  use  of  correct- 
ing lenses,  and  educative  treatment,  although  some  methods 
of  the  latter  cannot  be  used  effectively,  until  the  patient 
is  old  enough  to  read  and  give  some  account  of  his  sensa- 
tions, and  to  appreciate  instruction. 

Prognosis. — The  prospect  of  complete  cure  of  squint 
depends  largely  on  the  patient's  capacity  for  full  binoc- 
ular vision.  If  blindness  in  one  eye,  or  inability  to 
fuse  the  true  and  false  images,  prevents  this,  a  com- 
plete cure  is  impossible  ;  the  approximate  removal  of  the 
deformity,  rendering  it  less  noticeable,  is  all  that  can  be 
expected.  The  effect  that  will  be  produced  by  an  opera- 
tion can  never  be  predicted  with  certainty ;  hence,  the 


DISORDERS  OF  OCULAR  MOVEMENTS.          225 

prognosis  as  to  the  results  of  an  operation,  or  the  neces- 
sity of  a  subsequent  operation,  should  always  be  guarded. 
If  the  refraction  and  the  strength  of  the  different  muscles 
have  been  carefully  studied,  and  the  operation  has  been 
properly  chosen,  and  not  done  at  too  early  an  age,  there 
is  little  danger  of  those  subsequent  deviations  which 
in  an  earlier  generation  brought  the  operation  for  squint 
into  merited  discredit. 

LATENT  SQUINT. 

When  a  patient  with  habitual  binocular  vision,  upon  hav- 
ing one  eye  covered,  allows  it  to  deviate,  he  is  said  to  have 
a  latent  squint.  The  assumption  is  that  the  position  taken 
when  binocular  vision  is  prevented  is  a  position  of  rest  or 
of  lessened  effort ;  that  binocular  vision  is  only  maintained 
by  a  special  exertion,  which  the  perfectly  balanced  eyes 
do  not  have  to  make.  This  is  clearly  the  case  in  paralytic 
squint  in  a  zone  between  the  portion  of  the  field  where 
movements  are  strictly  normal,  and  the  portion  where 
diplopia  occurs  in  spite  of  any  effort ;  or  in  a  case  of 
insufficiency  of  convergence,  before  the  effort  becomes 
too  great  to  be  sustained,  and  relative  divergence  occurs. 

Varieties. — Formerly  all  cases  of  latent  squint  were 
called  "  insufficiencies  of  the  ocular  muscles."  At  that 
time  only  those  here  classed  as  insufficiencies  were  gene- 
rally recognized.  Heterophoria  has  recently  been  used 
as  a  synonymous  term ;  but  its  proposer,  Dr.  Stevens, 
considered  chiefly  the  conditions  here  classed  as  heter- 
ophoria,  largely  ignoring  the  true  insufficiencies,  except  in 
so  far  as  provided  for  in  the  awkward  classification 
"  heterophoria  in  accommodation."  An  insufficiency  of 
an  ocular  muscle  is  a  latent  paralytic  squint.  Hetero- 
phoria is  latent  concomitant  squint.  The  distinction 
between  the  two  classes  of  cases  should  be  recognized  in 
diagnosis  and  treatment.  Muscular  Imbalance  is  another 
term  used  to  indicate  the  conditions  under  discussion. 

Insufficiency  may  involve  either  of  the  six  extra-ocular 
muscles,  giving  rise  to  the  same  deviations,  as  do  paraly- 

15 


226         HETEROPHORIA  AND  INSUFFICIENCIES. 

ses  of  these  muscles;  these  deviations  do  not  occur 
until  binocular  vision  is  prevented  as  in  the  tests  for 
latent  squint.  For  example,  insufficiency  of  the  right 
external  rectus  will  cause  latent  squint  only  when  the 
eyes  are  turned  to  the  right,  which  will  increase  the 
farther  they  are  turned  in  that  direction.  This  squint 
will  be  convergent ;  the  diplopia  it  causes,  homonymous. 
If  symptoms  arise  from  such  a  latent  squint,  they  will  be 
connected  with  the  turning  of  the  eyes  to  the  right.  Such 
a  condition  might  be  termed  a  paresis  of  the  external 
rectus  muscle  ;  but  for  practical  reasons,  the  term  paresis 
should  be  reserved  for  cases  of  incomplete  paralysis  in 
which  the  squint  is  not  wholly  latent,  diplopia  occurring  in 
a  portion  of  the  field.  The  other  insufficiencies  recognized 
in  practice  are  insufficiencies  of  certain  muscle-groups, 
as  of  the  muscles  supplied  by  the  oculomotor  nerve ;  and 
insufficiencies  of  certain  movements,  as  insufficiency  of 
vertical  movements  or  insufficiency  of  convergence. 

The  last  variety  is  of  most  practical  importance.  A 
tendency  to  relative  divergence  of  4  or  5  centrads  at  the 
ordinary  distance  for  near  work,  about  one-third  of  a 
meter,  must  be  regarded  as  normal.  Closer  than  this  the 
tendency  to  relative  divergence  increases  until  for  each 
pair  of  eyes  a  certain  point,  the  near-point  of  convergence, 
is  reached.  But  quite  frequently  the  relative  divergence 
at  the  working  distance  is  found  greater  than  normal. 
Especially  in  presbyopes  and  myopes  this  is  the  case. 
A  majority  of  the  latter  show  marked  latent  divergence. 

Heterophoria,  a  tending  of  the  two  visual  lines  toward 
different  points,  is  a  departure  from  OrtJiojtJioria,  the 
tending  of  the  visual  lines  toward  the  same  point.  Its 
varieties  are  :  Esophoria,  latent  convergent  squint,  a  tend- 
ing of  the  visual  lines  to  intersect  nearer  than  the  point 
fixed  :  Exophoria,  latent  divergent  squint,  a  tending  of 
the  visual  lines  either  to  diverge  or  to  meet  beyond  the 
point  fixed  ;  and  Hyperphoria,  latent  vortical  squint,  a 
tending  of  one  visual  line  above  the  other.  The  term 
Cataphoria,  the  tending  of  one  visual  line  below  the  other 
is  unnecessary,  since  all  cases  of  latent  vertical  squint  are 


DISORDERS  OF  OCULAR  MOVEMENTS.          227 

either  right  hyperphoria,  tending  of  the  right  visual  line 
above  the  left,  or  left  hyperphoria,  a  tending  of  the  left 
visual  line  above  the  right.  Mixed  deviations  are  also 
recognized  as  hyper-esophoria,  where  one  eye  tends  to 
deviate  upward  and  inward. 

Causes. — The  causes  of  latent  squint  include  some  of 
the  causes  of  actual  squint,  opposed  by  a  well-developed 
power  of  binocular  co-ordination  and  fusion.  Take  away 
the  impulse  to  binocular  fusion,  and  the  squint  ceases  to 
be  latent. 

Symptoms. — Headache  and  eye-ache  are  the  most 
constant  symptoms  of  latent  squint,  while  vertigo  or  a 
sense  of  strain,  or  a  feeling  of  mental  confusion  may  be 
present  in  severe  cases.  The  headache  has  been  regarded 
as  more  likely  to  be  occipital  than  the  headache  due  to 
anomalies  of  refraction ;  but  there  is  no  very  marked 
difference  in  this  respect.  All  the  manifestations  of 
asthenopia  or  eye-strain  may  occur  in  connection  with 
latent  squint ;  but  congestion  and  inflammatory  changes 
either  in  the  eye  or  related  parts  are  less  common.  The 
connection  of  such  grave  nervous  disorders  as  epilepsy 
and  chorea  with  heterophoria  is  very  doubtful,  except  as 
heterophoria  arises  from  the  disturbance  of  the  ocular 
muscles  by  these  diseases.  In  a  few  cases,  actual  squint 
and  diplopia  may  be  discovered  at  times  or  in  parts  of 
the  visual  field,  in  patients  in  whom  such  deviation  of 
the  eyes  had  never  been  noticed. 

Diagnosis. — The  presence  of  latent  squint  is  revealed 
only  by  special  tests.  On  covering  one  eye,  that  eye  devi- 
ates ;  on  uncovering,  both  eyes  fix  normally.  The  move- 
ment of  deviation  is  often  quite  gradual,  occupying  some 
little  time  after  the  eye  has  been  covered,  and  on  this 
account  it  is  difficult  to  perceive.  But  the  movement  of 
readjustment,  or  "  recovery,"  is  instantaneous,  and  there- 
fore more  noticeable.  A  recovery  of  2  or  3  degrees  is 
readily  observed. 

But  entire  exclusion  of  one  eye  from  vision  is  not 
necessary  to  reveal  latent  squint.  Placing  before  one  eye 
a  piece  of  dark  blue  or  purple  glass  will  so  change  the 


228  DIAGNOSIS  OF  LATENT  SQUINT. 

color  of  an  ordinary  lamp-flame  as  to  overcome  the  ten- 
dency to  binocular  fusion.  The  eye  will  deviate,  and  a 
false  image  having  the  color  given  by  the  glass  will  be 
seen.  The  direction  of  the  false  image  and  the  distance 
of  its  separation  from  the  true  image  will  indicate  the 
kind  and  degree  of  the  squint. 

The  most  valuable  test  for  latent  squint  is  the  Maddox 
rod.  A  piece  of  glass  rod  placed  before  one  eye,  acting 
as  a  very  strong  cylinder,  produces  such  a  distortion  of 
the  images  formed  by  light  passing  through  it,  that  all 
tendency  to  fuse  them  with  the  images  of  the  other  eye 
is  overcome.  On  looking  at  a  point  of  light,  as  a  small 
flame  at  a  distance  of  4  to  6  meters,  this  appears  as  a 
long  streak,  perpendicular  to  the  direction  of  the  rod. 
If  the  balance  of  the  ocular  muscles  is  perfect,  this  streak 
appears  to  pass  directly  through  the  point  of  light  as  seen 
by  the  other  eye,  as  in  Fig.  83,  A.  But  in  latent  squint  the 


FIG.  83.— Positions  of  streak  of  light  seen  with  the  Maddox  rod  test:  A, 
orthophoria ;  B,  hyperphoria ;  C,  exophoria  or  esophoria,  according  as  the  rod 
is  held  before  the  right  or  the  left  eye. 

streak  appears  displaced  in  the  direction  opposite  that  of 
the  deviation.  Thus  if  there  be  a  right  hyperopia,  the 
rod  placed  before  the  right  eye  will  show  the  streak  below 
the  point  of  right,  as  in  Fig.  83,  B.  To  test  this  vertical 
balance  the  rod  is  placed  vertically,  causing  a  horizontal 
streak.  To  test  the  lateral  balance  it  is  placed  horizon- 
tally, causing  a  vertical  streak,  which  in  esophoria  or 
exophoria  appears  to  pass  to  the  right  or  left  of  the  light, 
as  in  Fig.  83,  O.  To  test  the  balance  at  the  near-work- 
ing distance,  a  point  of  light  is  not  readily  used  and 
a  white  spot,  1.5  to  2  mm.  square,  on  a  black  card, 


DISORDERS  OF  OCULAR  MOVEMENTS.          229 

is  substituted.  The  ordinary  Maddox  rod  gives  with 
such  a  spot  so  feeble  a  streak  that  it  is  better  to  employ  a 
piece  cut  from  the  side  of  a  large  rod,  or  a  cylindrical 
lens  of  20.  or  30.  D.  refracting  power. 

The  Graefe  Test  consists  in  placing  with  its  base 
directly  up  before  one  eye,  a  prism  strong  enough  (8 
or  10  degrees)  not  to  be  "overcome"  by  the  turning 
of  one  visual  axis  lower  than  the  other :  this  causes 
vertical  diplopia.  On  looking  at  a  black  dot  on  a  white 
card,  two  images  of  the  dot  are  seen.  If  the  lateral  bal- 
ance of  the  muscles  be  perfect,  one  image  is  directly  below 
the  other;  if  there  be  latent  lateral  squint,  the  lower 
image  will  be  displaced  laterally.  Graefe  proposed  this 
test  to  detect  insufficiency  of  convergence.  It  is  less 
useful  for  testing  the  vertical  balance. 

The  Maddox  double  prism  consists  of  two  prisms 
ground  on  one  piece  of  glass,  base  to  base.  It  is  placed 
before  one  eye  so  that  the  line  joining  the  two  prisms 
passes  horizontally  across  the  pupil.  On  looking  at  a 
black  dot  on  a  white  card,  the  eye  behind  the  prism  sees 
one  image  displaced  upward  and  another  downward ; 
while  with  the  other  eye  the  dot  appears  in  its  true  posi- 
tion. If  the  muscular  balance  is  perfect,  the  three  images 
are  seen  in  line,  the  true  image  being  just  midway  be- 
tween the  false  images.  Any  lateral  displacement  of  the 
images  indicates  tendency  to  lateral  deviation  ;  any  verti- 
cal displacement  a  tendency  to  vertical  deviation. 

To  measure  the  extent  of  a  latent  squint  prisms  are 
used.  The  prism  that  will  rectify  the  displacement  of 
the  false  image  indicates  the  amount  of  deviation  present. 
Such  a  prism  being  placed  before  the  eye,  no  movement 
of  deviation  or  recovery  occurs  on  covering  or  uncover- 
ing. With  the  dark  glass,  such  a  prism  causes  the  true 
and  false  images  to  come  together ;  with  the  Maddox  rod 
it  causes  the  streak  to  pass  through  the  image  of  the 
light ;  with  the  Graefe  test  it  brings  the  one  dot  directly 
below  the  other ;  with  the  double  prism  the  true  and  false 
images  come  in  line  and  are  equidistant. 

The  prisms  furnished  in  the  trial  case  are  sufficient  for 


230  MEASUREMENT  OF  HETEROPHORIA. 

the  above  tests.  But  special  instruments  have  been  de- 
vised to  facilitate  such  measurements  by  combining  with 
the  Maddox  rod  or  the  Graef  e  test  some  form  of  rotary 
prism. 

The  Stevens  phorometer  is  such  an  instrument,  based 
on  the  Graef  6  test,  and  fitted  for  the  very  accurate  placing 
of  the  prisms.  The  little  instrument  devised  by  the 
author  and  illustrated  in  Fig.  84  combines  the  rotary 


FIG.  84. — Phorometer  combining  Maddox  rod  and  rotary  prism. 

prism  with  the  Maddox  rod.  It  measures  slight  devia- 
tions with  great  accuracy ;  and  up  to  10  centrads. 
Higher  deviations  must  be  partly  corrected  by  a  10  or  20 
centrads  prism  before  the  other  eye,  and  then  the  remain- 
ing deviation  can  be  measured  by  this  instrument. 

Rotary  deviation  is  rendered  evident  by  use  of  a  test 
giving  a  linear  image.  Thus  with  the  prism  base  up 
or  the  double  prism,  a  horizontal  line  is  substituted  for 
the  dot.  If  there  is  no  rotary  deviation  of  the  eye,  such 
as  has  been  spoken  of  when  considering  paralytic  squint, 
the  true  and  the  false  images  of  the  line  remain  parallel. 
If  there  is  rotary  deviation,  the  image  belonging  to  the 
deviating  eye  will  appear  to  be  rotated  in  the  opposite 
direction.  The  lines  of  light  given  by  two  Maddox  rods, 
placed  one  before  each  eye,  may  also  be  used  in  the  same 
way ;  and  the  angle  over  which  they  must  be  rotated,  to 
make  the  two  lines  appear  parallel,  gives  the  amount  of 
rotary  deviation. 


DISORDERS  OF  OCULAR  MOVEMENTS.          231 

To  discriminate  between  an  insufficiency  and  a  heter- 
ophoria,  the  latent  squint  must  be  studied  in  different 
parts  of  the  field  of  fixation.  Usually  it  will  suffice  to 
note  the  deviation  with  the  eyes  directed  forward  ;  turned 
strongly  to  the  right  (or  face  to  the  left),  eyes  turned  to 
the  left  (or  face  to  the  right) ;  the  eyes  turned  up  (or  head 
thrown  forward),  turned  down  (head  thrown  backward) ; 
and  with  the  eyes  turned  to  the  ordinary  position  for 
reading  or  other  work. 

In  deciding  on  the  proper  course  to  be  pursued  with 
reference  to  a  case  of  latent  squint,  it  is  also  important  to 
ascertain  the  amount  of  abduction,  adduction,  and  sur- 
sumduction  (see  p.  192). 

This  is  most  conveniently  done  with  a  rotary  prism  by 
which  any  prismatic  effect  from  0  to  30  centrads  may  be 
obtained.  The  form  suggested  by  the  author  (see  Fig. 


FIG.  85.— Rotary  variable  prism. 

85),  measures  even  the  smallest  degrees  of  deviation  with 
great  accuracy. 

Treatment. — Where  the  latent  squint  is  of  moderate 
amount  and  the  power  of  "  overcoming  "  prisms  with  the 
base  in  the  direction  of  the  deviation  good,  or  where  there 
coexists  a  considerable  error  of  refraction  or  other  prob- 
able cause  for  the  symptoms,  the  tendency  to  squint  may 
be  disregarded,  at  least  until  other  factors  in  the  case 
have  been  looked  after.  In  all  cases  where  a  notable 


232  TREATMENT  OF  LATENT  SQUINT. 

error  of  refraction  exists,  its  correction  should  take  pre- 
cedence of  any  operative  treatment  for  the  muscular  faults. 

In  many  cases  heterophoria  is  an  important  indication 
regarding  the  wearing  01  correcting  lenses.  Thus  with  a 
moderate  or  low  hyperopia  the  existence  of  two  or  three 
centrads  of  esophoria  emphasizes  the  need  for  the  constant 
wearing  of  correcting  lenses. 

If  the  latent  squint  is  considerable  (2  centrads  or  up- 
ward of  vertical  deviation,  4  to  8  Cr.  of  divergence  or 
convergence),  prisms  should  be  tried.  Prisms  for  this 
purpose  do  not  strictly  "  correct "  a  deviation,  they  allow 
it  without  strain  or  inconvenience.  Thus  for  exophoria 
we  use  prisms  with  their  bases  toward  the  nose.  These 
allow  the  eye  to  turn  out  somewhat  while  still  preserving 
binocular  vision.  In  general,  the  strength  of  the  prisms 
used  in  this  way  should  be  such  as  to  "allow"  half  of 
the  deviation  ;  but  sometimes  nearly  the  whole  deviation 
may  be  "  allowed  "  with  advantage. 

If  lenses  are  worn,  the  prismatic  effect  may  be  attained 
with  great  accuracy,  and  with  least  expense,  by  decenter- 
ing  the  lenses.  When  an  eye  looks  through  any  part  of 
a  lens,  except  its  optical  center,  the  effect  is  that  of  a 
prism  with  its  base  at  the  thickest  part  of  the  lens.  Thus 
decentering  a  convex  lens  "  in,"  or  a  concave  lens  "  out," 
gives  the  effect  of  a  prism  with  its  base  toward  the  nose. 
Decentering  a  convex  lens  "  up,"  or  a  concave  lens  "  down," 
gives  the  effect  of  a  prism  with  its  base  up.  The  pris- 
matic effect  increases  as  the  optical  center  of  the  lens  is 
departed  from.  Thus  by  removing  the  optical  center  a 
certain  distance  from  the  point  where  the  visual  line  will 
pierce  the  lens,  any  desired  prismatic  effect  can  be  ob- 
tained up  to  the  limits  of  the  strength  of  the  lens  and 
the  size  of  the  glasses. 

The  greater  the  effect  to  be  produced  the  greater  must 
be  the  decentering ;  and  the  stronger  the  lens  the  less  it 
needs  to  be  decentered.  For  all  practical  purposes  the 
number  of  millimeters  of  decentering  required  in  any 
given  case  may  be  found  by  the  following  rule ;  multiply 
the  required  centrads  of  deviation  by  ten,  and  divide  by 


DISORDERS  OF  OCULAR  MOVEMENTS.          233 

the  strength  of  the  lens  in  diopters.  Thus  to  find  the 
decentering  of  a  4.  D.  lens  necessary  to  produce  2  centrads 
of  prismatic  effect  2X10-^-4  =  5  ram. 

Systematic  exercise  of  the  ocular  muscles  by  an 
entirely  different  use  of  prisms  is  sometimes  of  great 
value.  For  this  purpose  the  prism  is  turned  so  as  to 
increase  temporarily  the  work  of  the  apparently  weak 
muscles,  in  the  hope  of  thus  securing  a  better  develop- 
ment and  stronger  action  of  them.  Thus  for  right  hyper- 
phoria  the  eyes  may  be  fixed  on  a  distant  object,  and  a 
rotary  prism  be  placed  before  the  right  eye  with  its  base 
up,  making  necessary  an  increased  exertion  of  the  muscles 
that  turn  the  right  eye  down  or  the  left  eye  up.  The 
prism  being  turned  so  as  to  increase  its  effect,  the  patient 
is  told  to  keep  the  object  looked  at  single  as  long  as 
possible.  When  doubling  occurs,  the  prism  is  removed 
or  turned  back,  and  the  eyes  permitted  to  rest  a  minute  ; 
then  the  exercise  is  repeated.  For  latent  convergent 
squint,  the  eyes  may  be  made  to  fix  a  near-point,  while 
strong  prisms  are  placed  before  them  with  the  bases 
toward  the  nose ;  then  the  point  of  fixation  is  withdrawn 
from  the  eyes  until  it  appears  double,  when  the  eyes  are 
allowed  to  rest.  For  insufficiency  of  convergence,  prisms 
with  base  toward  the  nose  may  be  used.  The  fixing  of  a 
point  held  at  some  distance  from  the  eyes,  which  is  then 
gradually  brought  closer  and  closer  until  it  is  seen  double  in 
spite  of  a  strong  effort,  is  also  a  simple  and  efficient  exercise. 

Operations  on  the  ocular  muscles,  for  latent  squint,  are 
only  to  be  considered  after  the  most  careful  study  of  the 
case  and  the  faithful  trial  of  other  therapeutic  measures. 
They  exert  a  powerful  mental  effect  on  the  patient,  which 
is  sometimes  markedly  beneficial.  They  break  up  for 
the  time  vicious  habits  of  using  the  eye-muscles  with  un- 
necessary strain ;  and  they  may  change  permanently  the 
state  of  the  ocular  balance,  but  not  always  with  much 
benefit  to  the  patient.  The  extent  of  the  permanent 
mechanical  effect  cannot  certainly  be  known  beforehand, 
or  by  testing  at  the  time  of  operation,  or  immediately 
afterward.  Operation  should  only  be  resorted  to  for 


234  OPERATIONS  FOR  HETEROPHORIA. 

its  mechanical  effect  when  the  extent  of  the  latent  lateral 
deviation  amounts  to  10  centrads  (5  degrees)  or  upward, 
or  the  vertical  deviation  to  one  half  as  much ;  and  where 
the  relief  by  the  wearing  of  prisms  has  seemed  to  demon- 
strate the  connection  of  the  symptoms  with  the  latent 
squint.  Tenotomy  may  be  done  on  the  muscle  which 
tends  to  turn  the  eye  too  strongly  in  its  direction,  or 
advancement  upon  its  antagonist.  The  latter  operation, 
if  done  without  complete  division  of  the  tendon  or  great 
disturbance  of  neighboring  parts,  is  the  less  liable  to  cause 
untoward  effects. 

The  extent  to  which  the  symptoms  associated  with 
latent  squint  are  really  due  to  it  is  still  uncertain.  Often 
the  careful  trial  of  all  therapeutic  measures  is  called  for 
in  such  cases.  This  must  include  the  use  of  general 
tonics,  avoidance  of  eye-strain,  worry,  overwork,  or  the 
habitual  use  of  such  nerve-poisons  as  alcohol,  tobacco, 
tea,  or  coffee,  particularly  by  young  persons.  Outdoor 
life  and  physical  exercise  are  also  of  great  value. 

Prognosis. — The  permanent  relief  of  the  symptoms 
associated  with  latent  squint  is  often  extremely  difficult. 
The  most  brilliant  cases  of  apparent  cure  of  symptoms 
are  liable  to  return  to  somewhat  their  original  condition 
in  a  few  months  or  years.  Those  cases  are  most  likely  to 
be  cured  in  which  the  use  of  correcting  lenses  gives  relief, 
or  in  which  it  is  possible  to  control  favorably  the  manner 
of  living.  A  good  many  are  rendered  comfortable  and 
kept  so  by  the  use  of  the  prisms,  or  decentered  lenses, 
which  "  allow  "  the  squint. 

SPASTIC  SQUINT. 

Deviations  of  the  eyes  due  to  spasm  of  the  ocular  mus- 
cles attend  hysterical  seizures  and  some  forms  of  brain- 
disease.  They  may  assist  in  the  general  diagnosis ;  but 
have  little  localizing  value,  and  require  no  treatment 
apart  from  that  of  their  cause. 

NYSTAGMUS. 

Nystagmus  is  a  slight,  rapid,  to-and-fro  movement  of 


DISORDERS  OF  OCULAR  MOVEMENTS.          235 

the  eyes,  most  frequently  from  side  to  side  (lateral  nystag- 
mus) ;  but  sometimes  up  and  down  or  wheel-like  (vertical 
or  rotary  nystagmus}.  Usually  both  eyes  exhibit  similar 
movements.  They  may  be  increased  by  efforts  to  use 
the  eyes  (intention  nystagmus).  It  is  commonly  associated 
with  imperfect  vision.  It  is  often  congenital,  but  may 
arise  in  connection  with  disease  of  the  central  nervous 
system,  especially  when  that  causes  blindness.  It  often 
occurs  in  miners  who  have  to  work  in  a  poor  light,  with 
the  eyes  directed  obliquely  upward  (miners'  nystagmus). 

In  most  cases  no  interference  with  vision  is  occasioned 
by  the  movements.  But  in  miners'  nystagmus,  and  in 
some  other  cases  where  it  comes  on  in  adult  life,  it  occa- 
sions apparent  movement  of  objects  looked  at,  and  annoy- 
ing vertigo.  When  associated  with  high  astigmatism,  it 
may  growr  less  or  cease  entirely  with  the  wearing  of 
correcting  lenses.  Recovery  from  miners'  nystagmus 
often  follows  change  of  occupation.  In  other  cases  little 
improvement  can  be  hoped  for. 

BIBLIOGRAPHY. 

Tests  and  Studies  of  the  Ocular  Muscles.  425  pp.  The  Clinical  Use 
of  Prisms.  180  pp.  E.  E.  Maddox,  John  Wright  &  Co., 
Bristol. 

Handbook  on  the  Muscular  Anomalies  of  the  Eye.  H.  F.  Hansell 
and  W.  Keber.  182  pp.  P.  Blakiston's  Son  &  Co.,  Philadel- 
phia, Pa. 

Movements  of  the  Eyeball  and  Their  Anomalies.  A.  Duane, 
"  American  Text-book." 

Motor  Anomalies  of  the  Eye,  A  New  Classification.  A.  Duane, 
"Annals  of  Ophthalmol.,"  Oct.,  1896,  Apr.,  1897;  also 
reprinted. 

The  Corneal  Reflex  for  Measuring  Squint.  Priestley  Smith,  "  Oph- 
thalmic Review,"  Feb.,  1892. 

A  New  Test  for  Heterophoria  (Maddox  Rod).  E.  E.  Maddox, 
"Ophthalmic  Review,"  May,  1890. 

Triple,  Rotary  Variable  Prism.  E.  Jackson,  "Archives  of  Oph- 
thalmology," Jan.,  1894. 

Variable  Prism  Phorometer.  E.  Jackson,  "  Trans.  Sect,  of  Ophthal., 
Amer.  Med.  Assoc.,"  1893;  "Ophthalmic  Review,"  Aug.,  1893. 

Mechanism  of  the  Eye  Movements.  Carl  Weiland,  "Archives  of 
Ophthalmol.,"  Jan.,  1898. 

Relation  of  Convergence  to  Accommodation.  A.  S.  Percival,  "  Oph- 
thalmic Review,"  Nov.,  1892. 


236          DISORDERS  OF  OCULAR  MOVEMENTS. 

Position  of  the  Eye  During  the  Listing  Rotation.     G.  Hay,  "  Trans. 

Amer.  Ophthalmol.  Soc.,"  1898. 
Eye  Paralyses.    J.   A.   Jeffries,  "Boston  Med.    and  Surg.  Jour.," 

Oct.  20  and  27,  1892. 
Traumatic  Abducens  and  Facial  Paralysis.     W.  B.  Marple,  "  New 

York  Eye  and  Ear  Infirmary  Reports,"  1897. 
Recurrent  Oculo-Motor   Palsy.     P.  C.  Knapp,  "  Boston   Med.  and 

Surg.  Jour.,"  Sept.  27,  1894. 
Recurrent  Paralysis  of  the  Ocular  Nerves.     Omerod    and    Spicer, 

"  Trans.  Oph.  Soc.  of  United  Kingdom,"  Mar.,  1896. 
Pathology   of  Divergent  and   Convergent   Strabismus.     E.   Hansen 

Grut,  "  Bowman  Lecture,"  1889. 
Strabismus,  A  Manual.     E.  Javal,  "Ophthalmic  Review,"  May  and 

June,  1896. 
Convergent  Strabismus,  Etiology  and  Educative  Treatment.    Priestley 

Smith,  "Bowman  Lecture,"  1898. 
Development  of  the  Operative  Treatment  of  Squint.     H.  Snellen, 

"Ophthalmic  Review,"  Aug.,  1898. 
Convergent   Squint.      Final    Results   of   Operations.      C.   S.   Bull, 

"  Trans.  Amer.  Ophthalm.  Soc.,"  1895. 
Results  of  Operation  for  Strabismus.     C.  Schweigger,  "Archives  of 

Ophthalmology,"  Jan.,  1895. 
Strabismus  with    Anomalous   Diplopia.      C.    H.   Thomas,    "Trans. 

Amer.  Ophthalmol.  Soc.,"    1894;   " Ophthal.  Review,"  Sept., 

1894. 
Amblyopia  from  Suppression;  Congenital  Imperfection  or  Disuse. 

L.  Connor,   "  Trans.  Sect,  on  Ophthal.,  Amer.   Med.  Assoc.," 

1897. 
Asthenopia  not  Connected  with  Hypermetropia.     E.  Dyer,  "Trans. 

Amer.  Ophthalmol.  Soc.,"  1865. 
Operations  on  the  Ocular  Muscles,  and  Heterophoria.     L.  Connor,  S. 

Theobald,  H.  F.  Hansell,  C.  H.  Thomas,  G.  C.  Savage,  G.  T. 

Stevens,  H.  Woods,  J.  W.  Park,  and  H.  Gradle,  "  Trans.  Sect. 

on  Ophthalmol.,  Atner.  Med.  Assoc.,"  1895. 
Exophoria  Curable  without    Operation.    G.  M.  Gould,  "Medical 

News,"  Oct.  14  and  Nov.  18,  1893. 
A  Clinical  Study  of  Hyperphoria.     J.  T.  Carpenter,  "  Trans.  Sect. 

on  Ophthalmol.,  Amer.  Med.  Assoc.,"  1897. 
Motor  Changes  in  the  Ocular  Apparatus,  Associated  with  Functional 

Neuroses.     Myles  Standish,  "  System  of  Dis.  of  Eye,"  vol.  iv. 
Anomalies  in  the  Function  of  the  Extrinsic  Ocular  Muscles.     F. 

Buller,  "Ophthalmic  Review,"  Dec.,  1897. 
New  Truths  in  Ophthalmology.     G.  C.  Savage,  Nashville. 
Declination  of  the  Vertical  Meridians  of  the  Retina.     G.  T.  Stevens, 

"  Archives  of  Ophthalmol.,"  Jan.,  1899. 
Congenital   Anomalies  of    Motions    of    the  Eye.     H.    R.   Swanzy, 

"Trans.  Ophthalmol.  Soc.  of  the  United  Kingdom,"  Oct.,  1897. 
Miners'  Nystagmus.  S.  Snell,  150  pp.,  John  Wright  &  Co.,  Bristol. 
Head-nodding  and  Nystagmus.  C.  J.  Aldrich,  "  Amer.  Jour,  of  the 

Medical  Sciences,"  Feb.,  1899. 


DISEASES  OF  THE  CONJUNCTIVA.  237 


CHAPTER   IX. 

DISEASES  OF   THE  CONJUNCTIVA. 

Hyperemia  (Dry  Catarrh). — The  appearance  of 
hyperemia  of  the  conjunctiva  has  already  been  described 
(p.  60).  It  is  commonly  attended  with  itching,  smarting, 
and  burning,  or  the  sense  of  a  foreign  body  in  the  eye, 
feeling  worse  at  night,  or  after  use  of  the  eyes,  or  ex- 
posure to  heat.  It  may  be  acute  or  chronic. 

Causes. — These  are,  for  acute  hyperemia,  local  irri- 
tants, as  dust  or  irritating  vapors,  excessive  exposure  to 
the  sun  or  strong  winds,  excessive  use  of  the  eyes,  or 
their  prolonged  use  when  tired,  indulgence  in  alcoholic 
beverages,  gout,  a  general  febrile  condition,  commencing 
inflammation  of  the  conjunctiva ;  and  acute  catarrh  of 
the  mucous  membranes  in  general,  especially  of  the  nasal 
mucous  membrane.  For  chronic  hyperemia  one  should 
always  search  for  a  persistent,  or  frequently  recurring, 
cause.  The  most  common  of  such  causes  are  :  eye-strain 
from  habitual  overwork  or  the  presence  of  ametropia ; 
chronic  hyperemia  of  the  nasal  and  related  mucous  mem- 
branes, including  catarrh  of  the  lacrimal  passages ;  re- 
peated attacks  of  acute  hyperemia ;  prolonged  exposure 
to  excessive  heat;  and  chronic  alcoholism. 

Treatment. — Acute  hyperemia  tends  strongly  to  spon- 
taneous recovery,  and  requires  only  removal  of  the  cause, 
rest  for  the  eyes,  and  some  soothing  collyrium,  such  as  a 
solution  of  boric  acid  with  or  without  borax.  Chronic 
hyperemia  requires,  first,  the  removal  of  the  cause,  and 
if  this  prove  insufficient,  some  of  the  milder  forms  of 
treatment  for  chronic  catarrhal  conjunctivitis.  The  re- 
moval of  the  cause,  however,  may  include  relief  from 
eye-strain,  or  long  and  careful  general  treatment,  as  to 
overcome  a  general  oatarrhal  tendency. 

Acute  Catarrhal  Conjunctivitis  (Simple  Ophthal- 
mia, Catarrh  of  Conjunctiva,  Mucopurulent  Conjunctivitis). 
— When  to  hyperemia  are  added  swelling  of  the  conjunc- 


238          ACUTE  CATARRHAL  CONJUNCTIVITIS. 

tiva  and  conjunctival  discharge,  the  case  becomes  one  of 
conjunctivitis. 

Causes. — The  causes  include  all  those  of  conjunctival 
hyperemia.  The  instillation  of  atropin  or  other  mydriatic 
causes  or  aggravates  conjunctivitis  in  a  few  persons  who 
have  such  an  idiosyncrasy.  There  can  be  no  doubt  that 
certain  pathogenic  bacteria  are  the  essential  factors  in  the 
causation  of  many  cases  of  acute  conjunctivitis.  Among 
the  most  important  of  these  are  the  pus  cocci,  the  staphy- 
lococci,  and  streptococcus,  and  the  lanceolate  encapsuled 
diplococcus  (pneumococcus  of  Frankel).  These  are  found 
in  cases  which  must  still  be  classed  together  by  their 
clinical  characteristics.  The  other  organisms  causing 
distinct  clinical  types  of  disease  are  mentioned  in  the 
descriptions  of  those  types  of  conjunctivitis. 

Symptoms. — The  discharge  of  acute  catarrh  of  the 
conjunctiva  is  at  first  scanty  and  may  be  only  apparent 
by  the  adhesion  of  the  lids  in  the  morning,  after  it  has 
dried  upon  their  margins  throughout  the  night.  It  may 
amount  to  but  a  slight  increase  of  the  normal  secretion, 
which  is  washed  away  by  the  usual  or  increased  secretion 
of  the  tears.  As  the  case  progresses  the  amount  of  dis- 
charge increases ;  and  its  character  may  vary  to  the 
abundant  flow  of  purulent  conjunctivitis.  Small  masses 
of  the  discharge  may  be  noticed  lying  at  the  junction  of 
the  lower  lid  and  eyeball,  or  may  be  found  in  the  lower 
cul-de-sac  of  the  conjunctiva,  upon  everting  the  lid. 

The  appearance  of  the  lids  varies  with  the  degree  of 
hyperemia,  the  changes  in  the  epithelium,  and  the  amount 
of  exudation  in  the  deeper  tissues.  The  hyperemia  gives 
increased  redness,  which  may  appear  only  in  the  larger 
number  or  larger  size  of  the  visible  vessels.  Thickening 
of  the  epithelial  layer  masks  the  increase  of  redness  and 
gives  the  appearance  of  a  gray  film  upon  the  surface  of 
the  conjunctiva.  Exudation  into  the  deeper  tissues,  by 
separating  the  vessels  and  by  pressure  upon  them  reduc- 
ing their  caliber,  tends  to  diminish  the  redness,  sometimes 
to  even  less  than  the  normal. 

The  pain  of  acute  conjunctivitis  is  usually  most  marked 


DISEASES  OF  THE  CONJUNCTIVA.  239 

early  in  the  course  of  the  disease,  is  strictly  local,  and 
may  vary  from  a  slight  discomfort  to  severe  burning  pain. 
To  some  extent  it  is  proportioned  to  the  severity  of  the 
inflammation,  but  it  also  depends  somewhat  on  the  condi- 
tion of  the  nervous  system.  It  resembles  that  of  simple 
hyperemia,  and  is  described  in  many  ways,  but  usually  as 
more  or  less  of  an  itching,  smarting,  scratching,  or  burn- 
ing character.  It  may  be  spoken  of  as  aching,  though 
probably  true  aching  when  present  is  connected  with  consid- 
erable swelling  of  the  neighboring  parts,  or  involvement  of 
the  deeper  tissues  of  the  eyeball.  In  the  early  stages  there 
is  often  the  exact  sensation  of  a  foreign  body  in  the  eye. 

Exudation  in  conjunctivitis  occurs  within  the  tissues, 
causing  swelling,  or  upon  their  surface  as  discharge.  It 
is  generally  accompanied  by  loss  of  transparency,  so  that 
the  deeper  details  normally  visible  through  the  conjunc- 
tiva are  hidden.  It  involves  largely  the  loose  tissues 
lying  beneath  the  membrane,  and  if  severe,  affects  the 
whole  thickness  of  the  lids.  On  the  eyeball  the  tissues 
affected  are  thickest  posteriorly  where  the  membrane  is 
reflected  upon  the  lids ;  hence,  if  the  swelling  be  slight 
or  moderate  in  amount,  it  is  most  noticeable  in  this 
region.  If,  however,  the  amount  of  serous  exudate  be 
great,  the  pressure  posteriorly  tends  to  force  it  forward, 
so  that  it  raises  up  the  conjunctiva  to  its  attachment 
around  the  cornea  ;  and  the  cornea  appears  surrounded 
by  a  perpendicular  or  overhanging  wall  of  translucent 
tissue.  This  condition  is  called  chemosis. 

Careful  examination  of  the  affected  tissue  will  often 
show  that  it  is  the  seat  of  numerous  minute  hemorrhages. 
The  swelling  of  the  conjunctiva,  however  great,  never 
endangers  the  integrity  of  that  membrane.  But  chemosis 
is  supposed  by  pressure  to  interfere  with  the  zone  of 
vessels  upon  which  the  nutrition  of  the  cornea  depends ; 
and  the  sulcus  formed  by  it  at  the  corneal  margin  cer- 
tainly favors  the  retention  of  the  discharges,  and,  in  that 
way,  the  infection  of  the  cornea. 

Discharge  from  the  conjunctiva  consists  of  increased 
normal  secretion  and  cast-off  epithelium,  with  a  variable 


240          ACUTE  CATARRHAL  CONJUNCTIVITIS. 

proportion  of  pus  and  micro-organisms.  If  the  propor- 
tion of  pus  be  small,  the  masses  found  floating  in  the  tears 
will  be  gray  or  whitish  in  color  and  rather  stringy  in 
appearance.  As  the  proportion  increases,  the  discharge 
becomes  more  purulent  in  character,  and  sometimes  is 
decidedly  so,  even  in  cases  that  would  be  classed  as 
catarrhal  conjunctivitis.  At  all  times  the  apparent 
amount  of  discharge  and  its  consistence  depend  largely 
on  the  extent  to  which  it  is  diluted  by  the  lacrimal  secre- 
tion. In  the  earlier  stages  the  increased  flow  of  tears  is 
liable  to  carry  away  all  other  discharges  unnoticed.  Later, 
the  secretion  of  tears  is  less  copious,  and  the  amount  of 
mucous  or  purulent  matter  appears  relatively  greater. 

Diagnosis. — The  hyperemia  of  conjunctivitis  is  to  be 
distinguished  from  that  of  keratitis,  iritis,  or  glaucoma,  etc. 
(see  p.  61).  From  other  forms  of  acute  conjunctivitis  the 
catarrhal  often  cannot  be  differentiated  at  the  outset,  except 
that  the  symptoms  are  generally  less  violent  than  in  puru- 
lent or  diphtheritic  conjunctivitis.  The  differentiation 
from  more  chronic  forms  must  also  wait  until  these  have 
time  to  develop  their  special  characteristics.  The  bacter- 
iological examination  and  identification  of  the  organisms 
present  will  in  some  cases  be  the  only  way  of  deciding 
whether  or  not  the  case  belongs  in  this  class,  or  one  of  the 
specific  forms  of  conjunctivitis.  The  special  clinical 
characters  of  the  other  forms  of  conjunctivitis  discussed 
in  connection  with  them  furnish  a  basis  for  their  differen- 
tial diagnosis  from  this  variety. 

Treatment. — After  the  removal  of  the  cause,  so  far  as 
it  is  removable,  the  treatment  consists  largely  in  rest  and 
cleanliness.  The  rest  of  the  eyes  should  be  supplemented 
by  general  rest,  if  the  inflammation  be  severe  ;  and  should 
always  include  sufficient  sleep.  Cleanliness  is  to  be 
secured  by  frequent  bathing  of  the  eye,  with  the  free 
instillation  of  a  solution  of  boric  acid  and  borax  or  sodium 
chlorid,  at  intervals  of  from  one  to  four  hours,  according 
to  the  amount  of  discharge.  Weak  solutions  of  mercuric 
chlorid,  mercuric  iodid,  or  oxycyanid  may  be  used  for  the 
same  purpose.  But  in  catarrhal  conjunctivitis  care  should 


DISEASES  OF  THE  CONJUNCTIVA.  241 

always  be  taken  to  avoid  solutions  strong  enough  to  act 
as  irritants,  their  cleansing  power  being  far  more  impor- 
tant than  their  specific  antiseptic  influence.  When  the 
case  is  seen  early  and  appears  severe,  its  course  will  be 
shortened  by  using  one  or  more  applications  of  a  solution 
of  silver  nitrate  or  protargol ;  and  if,  at  a  later  stage,  the 
discharge  is  profuse  or  tends  to  continue  more  than  a  few 
days,  the  same  remedies  are  indicated.  In  the  way  of 
general  treatment,  the  use  of  a  laxative  and  the  treatment 
of  any  coincident  departure  from  health  may  be  needed. 

Prognosis. — Unless  the  cause  cannot  be  removed  or 
avoided,  the  prognosis  of  acute  catarrhal  conjunctivitis 
is  favorable,  recovery  being  complete  in  a  few  days. 

Exanthematous  Conjunctivitis. — The  early  stage 
of  measles,  small-pox,  scarlet  fever,  and  some  of  the 
other  exanthemata  is  frequently  marked  by  conjunctival 
hyperemia  and  catarrh,  to  which  the  above  name  has  been 
given.  It  is  characterized  rather  by  hyperemia  and  swell- 
ing without  much  discharge,  although  with  measles  and 
scarlet  fever  the  conjunctival  secretion  may  even  become 
purulent,  and  in  small-pox  well-marked  examples  of  the 
eruption  may  be  found,  on  the  bulbar  conjunctiva,  espe- 
cially near  the  corneal  margin.  Usually  the  conjunctival 
trouble  quickly  subsides,  but  it  may  require  treatment 
even  after  the  constitutional  disease  has  run  its  course. 

Acute  contagious  conjunctivitis  is  a  specific  dis- 
ease caused  by  infection,  the  active  agent  being  a  small 
bacillus  first  studied  by  Weeks,  and  which  may  be  found 
in  the  conjunctival  discharges. 

Symptoms  and  Course. — It  begins  two  or  three  days 
after  infection,  with  glueing  together  of  the  lids  and  the 
appearance  of  dry  yellowish  masses  on  their  margins  or 
about  the  inner  canthus,  especially  in  the  morning. 
Hyperemia  and  discharge  rapidly  increase  for  two  or 
three  days,  and  the  discharge  often  becomes  purulent. 
The  deeper  fine  vessels  of  the  eyeball  are  much  injected, 
giving  it  a  pink  appearance.  Hence  the  popular  name  of 
"  pink-eye."  There  is  also  usually  some  involvement  of 
the  upper  air-passages  and  adjoining  sinuses,  causing 

16 


242         ACUTE  CONTAGIOUS  CONJUNCTIVITIS. 

slight  coryza.  The  common  course  of  the  disease  is  to 
complete  recovery  in  a  few  days,  but  it  may  become  sub- 
acute  and  continue  for  several  weeks.  It  appears  to 
spread  by  direct  contact,  extending  to  the  diiferent  mem- 
bers of  a  family,  or  through  a  school  or  barracks.  It  may 
cause  marginal  ulceration  or  haziness  of  the  cornea. 

Diagnosis. — From  catarrhs!  conjunctivitis  it  can  be 
distinguished  by  the  peculiar  yellow  secretion  adherent  to 
the  lashes,  the  occurrence  of  other  cases  in  the  same 
house,  either  before  or  afterward ;  and  by  the  identifica- 
tion of  the  Weeks'  bacillus  with  the  microscope.  It  is  a 
small  bacillus  resembling  that  of  mouse  septicemia.  It 
stains  readily  with  methylene  blue,  and  loses  its  color  by 
the  Gram  method.  It  is  found  within  the  cells  and  also 
free  in  the  discharge.  It  is  difficult  to  obtain  in  pure 
culture,  being  generally  mixed  with  a  club-shaped  non- 
pathogenic  bacillus. 

A  form  of  acute  contagious  conjunctivitis  which  many 
observers  have  been  unable  to  distinguish  from  the  above 
seems  to  be  caused  by  the  pneumococcus  (Fraenkel) ;  an 
ovoid  or  lanceolate  encapsulated  coccus  often  found  in 
pairs,  hence  called  the  mierococcus  lanceolatus  (Talamon), 
or  the  diplococcus  pneumonia;  (Weichselbatim).  It  exists 
in  the  normal  saliva  of  many  persons. 

Treatment. — This  will  generally  be  similar  to  that  of 
acute  catarrhal  conjunctivitis.  Cold  applications  may  be 
used  the  first  two  or  three  days.  The  more  severe  cases 
should  be  treated  by  applications  to  the  everted  lids  of  a 
2  percent,  solution  of  silver  nitrate,  repeated  every  day 
or  two,  until  the  discharge  and  swelling  are  markedly 
diminished. 

Diplobacillus  conjunctivitis  is  characterized  by 
comparatively  slight  discharge,  often  only  noticed  by  the 
glueing  together  of  the  lashes  after  sleep.  There  is 
moderate  irritation  and  smarting,  chiefly  in  the  evening. 
Many  of  the  cases  run  a  stibacute  or  chronic  course,  ex- 
tending over  many  weeks  or  months.  The  invasion  is  gener- 
ally insidious,  but  the  attack  is  sometimes  acute ;  and  the 
more  severe  cases  may  be  taken  for  commencing  trachoma. 


DISEASES  OF  THE  CONJUNCTIVA.  243 

The  cause  is  a  bacillus,  first  described  by  Morax  and 
Axenfeld,  each  rod  being  2  or  3  micro-millimeters  in 
length,  and  one-half  as  thick,  commonly  arranged  in 
pairs  (diplobacilli).  Gifford  says  it  is  encapsulated.  It 
grows  readily  upon  serum  and  serum-agar. 

The  treatment  recommended  by  most  observers  is 
essentially  the  instillation  of  a  solution  of  zinc  sulphate. 
Gifford  found  it  yielded  quickly  to  a  solution  of  zinc 
chlorid,  £  of  1  per  cent.  Alt  used  a  2  per  cent,  solution 
of  protargol  with  good  effect. 

Ophthalmia  nodosa  is  an  inflammation  of  the  con- 
junctiva, sometimes  extending  to  the  deeper  tissues  of  the 
eye,  due  to  the  presence  of  caterpillar  hairs.  The  con- 
junctivitis tends  to  relapse  again  and  again,  and  where 
each  hair  is  embedded,  a  rounded  gray  swelling  is  formed. 
Excision  of  the  offending  particle,  which  may  be  extremely 
minute,  is  the  proper  treatment. 

Brief  Recurring  Bpiscleritis. — Under  the  name 
Episderitis  Periodica  Fugax,  Fuchs  described  a  form  of 
conjunctival  and  episcleral  hyperemia,  attended  with 
pain,  but  without  discharge ;  lasting  but  a  few  days,  but 
recurring  at  intervals  of  a  week  to  several  months.  In 
some  cases  it  lasts  for  many  years.  It  seems  to  depend 
on  some  obscure  condition  of  the  general  system  ;  and  is 
little  benefited  by  treatment. 

Purulent  Conjunctivitis.  (Purulent  Ophthalmia, 
Acute  Blcnnorrhea,  Gonorrheal  Ophthalmia,  Ophthalmia 
Neonatorum). — This  affection  is  characterized  by  great 
swelling  of  the  conjunctiva  and  lids,  and  abundant  dis- 
charge, at  first  serous  and  later  purulent. 

Cause. — In  most  cases  this  is  the  implantation  upon 
the  conjunctiva  of  the  gonococcus,  by  contact  with  fingers 
or  clothing  carrying  the  infective  material ;  or  by  similar 
contact  in  the  birth-canal  during  labor.  Disease  clinically 
similar  may  be  produced  by  other  pyogenic  organisms. 

Symptoms  and  Course. — Within  one  or  two  days  after 
infection  the  eye  presents  the  symptoms  of  acute  catarrhal 
conjunctivitis,  rapidly  increasing  in  severity,  with  exces- 
sive swelling  of  the  lids  and  free  discharge.  This  dis- 


244  PURULENT  CONJUNCTIVITIS. 

charge  is  at  first  clear  and  watery,  then  it  contains  shreds 
and  flakes  of  mucus  and  may  be  discolored  by  blood. 
Gradually  it  becomes  more  purulent,  until  it  has  the 
appearance  of  typical  creamy,  or  slightly  greenish,  pus. 
The  first  indication  of  the  gravity  of  the  attack  is  found 
in  the  severity  of  the  symptoms  and  the  rapidity  of  their 
progress.  The  lids,  in  the  early  stage  are  tense,  often 
smooth  and  shiny.  The  swelling  of  the  conjunctiva  gives 
rise  to  chemosis,  and  interferes  considerably  with  the  ever- 
sion  of  the  lids.  When  the  discharge  becomes  purulent, 
the  lids  generally  become  softer,  and  the  swelling  dimin- 
ishes. In  a  few  days  the  palpebral  conjunctiva  shows 
hypertrophy  of  the  papillae.  Its  surface  becomes  velvety 
in  appearance,  and  later  may  be  obscured  and  covered  to 
a  depth  of  two  or  three  mm.,  with  the  pale,  or  dark-red 


FIG.  86.— Papillary  granulations  of  the  late  stage  of  purulent  conjunctivitis, 
shown  on  the  everted  upper  lid,  with  severe  hyperemia  of  the  bulbar  con- 
junctiva. 

granular  masses.  These  are  illustrated  in  Fig.  86.  The 
discharge,  under  treatment  rapidly,  or  without  treatment 
more  slowly,  diminishes ;  but  several  weeks  are  usually 
required  to  restore  the  conjunctiva  to  an  approximately 
normal  condition. 

A  common  complication  and  the  great  danger  of 
the  disease  is  involvement  of  the  cornea.  This  has 
been  thought  to  depend  chiefly  upon  the  pressure  of 
the  swollen  lids,  or  the  chemotic  conjunctiva ;  but  it 
may  occur  from  direct  infection  by  the  virulent  dis- 
charge that  bathes  it,  especially  where  this  lies  in 
contact  with  the  cornea,  in  the  crease  formed  by  the 
overlapping  of  the  swollen  conjunctiva.  When  this  occurs 
a  small  ulcer  forms  near  the  conical  margin,  which  rapidly 


DISEASES  OF  THE  CONJUNCTIVA.  245 

extends,  both  in  area  and  in  depth ;  or  a  considerable 
part  of  the  cornea — usually  at  the  center — rapidly  be- 
comes opaque  and  breaks  down,  leaving  a  large  extending 
ulcer.  Such  an  ulcer  is  liable  to  cause  perforation  and 
the  serious  or  fatal  results  described  under  suppurating 
ulcer  of  the  cornea  (Chapter  X).  In  debilitated  subjects, 
or  under  inefficient  treatment,  the  hypertrophy  of  the 
conjunctiva  above  described  is  liable  to  be  excessive  and 
to  continue,  with  moderate  discharge,  for  many  weeks. 

Varieties. — Gonorrhea!  ophthalmia  the  disease  is  called 
when  it  is  clearly  due  to  infection  with  the  virus  of 
gonorrhea,  or  the  gonococcus  is  found  in  the  discharge. 
Cases  of  this  character  include  the  most  serious  and 
dangerous  cases  of  purulent  ophthalmia. 

Ophthalmia  neonatorum  is  the  name  given  to  purulent 
conjunctivitis  in  the  new-born.  Infection  usually  occurs 
during  birth,  although  some  children  are  born  with  the 
inflammation  already  developed,  probably  having  been 
infected  after  early  rupture  of  the  membranes  in  a  slow 
labor.  A  few  cases  also  become  infected  subsequent  to 
labor,  from  lack  of  proper  cleanliness.  A  majority  of 
cases,  including  all  in  which  the  inflammation  is  most 
violent,  show  the  presence  of  the  gonococcus  in  the  dis- 
charge. Cases  of  ophthalmia  immediately  after  birth  do 
occur  that  clearly  have  a  different  origin  and  character. 

Diagnosis. — Purulent  conjunctivitis  is  to  be  first  sus- 
pected from  the  violence  of  the  symptoms  of  conjunctival 
inflammation ;  the  extent  and  rapid  progress  of  the  swel- 
ling ;  and  the  free  watery  and  flaky  discharge.  Con- 
junctivitis coming  on  within  four  or  five  days  after  birth 
should  at  once  be  regarded  as  probably  purulent.  In 
adults  the  history  of  an  antecedent  urethral  or  vaginal 
discharge,  or  exposure  to  contagion,  can  usually  be 
obtained.  Later  the  profuse  secretion  of  the  thick  pus  is 
very  characteristic,  and  still  later  the  existence  of  large, 
soft,  dark-red  granulations,  covering  the  inner  surface  of 
the  lids,  is  suggestive  of  the  nature  of  the  case.  Micro- 
scopic examination  of  the  discharges  as  described  (p.  67), 
stained  with  methylene  blue,  and  also  tried  by  the  Gram 


246  PURULENT  CONJUNCTIVITIS. 

method,  may  be  necessary  to  decide  the  nature  of  doubt- 
ful cases.  Preparations  so  made  may  also  be  valuable  in 
regard  to  the  medico-legal  aspects  of  the  case. 

Treatment. — The  most  important  point  is  the  clean- 
sing of  the  eye  of  all  discharges  as  frequently  as  this 
becomes  necessary.  In  the  earliest  stage  the  free  watery 
discharge  may  so  far  accomplish  self-cleansing  that  other 
measures  are  of  more  practical  importance.  In  healthy 
adults,  where  the  swelling  is  great,  the  application  of  cold 
by  pledgets  of  lint  laid  on  a  block  of  ice  and  thence 
transferred  to  the  lid,  and  changed  every  one  or  two 
minutes,  is  often  employed.  When  the  swelling  begins 
to  diminish,  or  the  discharge  to  become  markedly  puru- 
lent, cold  is  of  less  value.  It  must  also  promptly  be 
discontinued  when  haziness  of  the  cornea  shows  that  its 
nutrition  is  being  interfered  with ;  and  is  not  to  be 
resorted  to  for  weak  patients.  Cold  is  difficult  to  apply 
efficiently  in  the  purulent  conjunctivitis  of  infancy,  and  is 
not  so  beneficial. 

When  seen  very  early  the  course  of  the  disease  may 
sometimes  be  modified  by  a  single  free  application  of  a 
strong  solution  of  silver  nitrate  ;  but  during  the  period 
of  watery  discharge  and  great  tension  of  the  lids,  such  an 
application  is  not  to  be  repeated. 

As  the  disease  passes  into  the  stage  of  free  secretion 
of  pus,  the  thorough  and  frequent  cleansing  of  the  eye 
becomes  of  the  highest  importance.  All  discharge  escap- 
ing from  the  palpebral  fissure  should  be  promptly  removed 
with  absorbent  cotton,  which  will  take  it  up  without  un- 
necessary wiping  of  the  lids.  As  often  as  every  hour  at 
the  height  of  the  disease,  or  even  more  frequently  if  the 
discharge  is  very  profuse,  the  conjunctival  sac  should  be 
thoroughly  washed  out,  and  all  shreds  clinging  to  its  sur- 
face be  removed  with  absorbent  cotton.  For  such  washing 
the  solution  may  be  of  boric  acid,  or  very  weak  solutions 
of  trikresol,  potassium  permanganate,  mercuric  chlorid  or 
cyanid,  or  formaldehyde.  The  important  points  are  that 
it  shall  be  used  freely  and  efficiently,  and  shall  not  be  so 
strong  as  to  act  the  part  of  a  local  irritant.  In  any  case 


DISEASES  OF  THE  CONJUNCTIVA.  247 

the  water  is  the  more  important  ingredient  of  the  solu- 
tion ;  and  the  object  to  be  aimed  at  is  the  complete 
mechanical  removal  of  discharges,  rather  than  their  de- 
struction or  neutralization  in  situ  by  the  chemical  anti- 
septic. For  such  washing,  various  irrigators  in  the  form 
of  hollow  lid  elevators,  or  specula,  perforated  for  the 
escape  of  the  solution,  have  been  devised ;  but  no  instru- 
ment will  be  efficient  without  careful  thoroughness  in  its 
use ;  and  the  rubber-bulb  pipette  will  do  as  well.  It 
should  have  a  perfectly  smooth  nozzle,  and  as  large  a 
bulb,  up  to  one  or  two  ounces,  as  is  obtainable.  The 
point  of  the  tube  is  to  be  inserted  between  the  lids  near 
the  outer  commissure,  and  the  solution  forced  into  the 
eye.  Care  must  be  taken  to  provide  for  the  subsequent 
disinfection  of  the  tube  when  allowed  to  come  in  contact 
with  the  lids,  as  by  allowing  it  to  stand  in  a  stronger 
antiseptic  solution  in  the  intervals.  As  the  discharge 
becomes  less,  the  intervals  between  the  washings  may  be 
lengthened.  But  it  must  be  insisted  that  the  frequent 
gentle  but  thorough  cleansing  of  the  eye  is  of  more  im- 
portance in  this  disease  than  all  other  remedial  measures 
taken  together. 

As  the  secretion  becomes  purulent  applications  of 
2  to  4  per  cent,  solutions  of  silver  nitrate,  or  20  to  40 
per  cent,  solutions  of  protargol  to  the  conjunctival  sur- 
face of  the  everted  lids  are  indicated.  Such  applica- 
tions may  be  repeated  daily,  occasionally  even  oftener, 
or  at  longer  intervals.  The  rule  must  carefully  be 
observed  not  to  repeat  the  application  of  the  nitrate  until 
the  red  and  rather  raw  appearance  of  the  lid,  which 
may  be  noticed  for  some  hours  after  an  application,  has 
given  place  to  the  usual  succulent  appearance  character- 
istic of  the  disease.  The  applications  of  such  solutions  are 
to  be  continued  at  lengthened  intervals  until  the  cure  of 
the  case  is  nearly  complete,  or  the  condition  has  changed 
into  one  of  chronic  conjunctivitis.  In  addition  a  2  per 
cent,  solution  of  protargol  may  be  instilled  every  two  or 
three  hours. 

Where  the  swelling  of  the  lids  is  very  great,  preventing 


248  PURULENT  CONJUNCTIVITIS. 

their  free  eversion  and  complete  cleansing,  and  causing 
considerable  pressure  upon  the  eyeball,  canthotomy  should 
be  practiced ;  or  in  infants,  the  upper  lid  may  be  divided 
by  a  vertical  incision  (see  Chap.  XIX). 

For  debilitated  patients  the  application  of  heed,  either 
by  cloths  wrung  from  water  of  a  temperature  of  130°  F. 
or  upward,  or  by  the  hot-water  coil,  or  the  Japanese  hot- 
box,  must  replace  the  application  of  cold  that  might  be 
resorted  to  in  the  more  robust.  When  involvement  of 
the  cornea  is  noted,  such  applications  of  heat  must 
replace  cold  in  all  cases.  To  be  effective  the  application 
of  cold  must  be  continuous  ;  but  high  degrees  of  heat  may 
be  used  for  short  periods,  five  to  twenty  minutes,  with 
intervals  of  three  to  four  hours  during  which  the  eye  is 
kept  moderately  warm.  Especial  treatment  directed 
toward  the  corneal  complications  will  be  referred  to 
in  Chapter  X,  on  Diseases  of  the  Cornea. 

The  general  treatment  may  include  rest  in  bed  until 
the  swelling  and  discharge  are  beginning  to  subside. 
Internally  it  is  well  to  commence  with  a  free  laxative  or 
decided  cathartic,  and  subsequently  to  give  quinin  and 
tincture  of  the  chlorid  of  iron,  the  latter  in  full  doses. 
If  the  patient  be  debilitated,  other  tonics  and  stimulants 
may  be  indicated  to  keep  up  the  nutrition  of  the  cornea. 
Pain,  if  severe,  may  be  met  with  small  doses  of  morphin 
or  acetanilid. 

Prophylaxis. — Scarcely  secondary  in  importance  to  the 
treatment  of  this  disease  are  certain  precautions  for  its 
prevention.  In  adults,  usually  but  one  eye  is  affected  in 
the  beginning,  and  the  greatest  care  should  be  taken  to 
avoid  the  conveyance  of  the  virus  to  the  second  eye.  To 
more  certainly  prevent  this,  when  the  first  eye  seems 
likely  to  be  lost,  it  is  advisable  to  close  the  second  eye 
with  an  impervious  dressing.  Linen  may  be  placed  upon 
the  lids,  over  this  a  compress  of  absorbent  cotton,  and  on 
this  some  protective,  the  whole  to  be  retained  by  collodion 
painted  all  around  the  margin  of  the  dressing.  If  it  be 
important  for  the  patient  to  be  able  to  see,  this  dressing 
may  be  replaced  by  a  large  watch-glass  made  fast  at  its 


DISEASES  OF  THE  CONJUNCTIVA.  249 

margin  by  strips  of  adhesive  plaster.  This  is  called 
Buller's  shield,  from  the  name  of  its  proposer.  Knapp 
uses  a  piece  of  mica,  and  leaves  the  temporal  margin  free 
for  circulation  of  air.  Through  it  the  patient  can  have 
the  use  of  the  sound  eye,  and  the  surgeon  can  watch  for 
any  indications  of  disease,  while  the  chances  of  infection 
are  reduced  to  a  minimum. 

At  birth  it  commonly  happens  that  both  eyes  are  in- 
fected during  the  passage  of  the  head  through  the  vagina, 
but  even  after  this  has  occurred  the  outbreak  of  the  dis- 
ease may  be  prevented.  To  accomplish  this  the  child's 
eyes  should  be  immediately  cleansed,  and  a  2  per  cent, 
solution  of  silver  nitrate  freely  instilled.  If  this  precau- 
tion, known  as  the  Crede  method,  be  adopted,  the  disease 
will  generally  be  prevented.  So  grave  a  calamity  is 
blindness  from  purulent  conjunctivitis  that  the  use  of 
this  precaution  has  been  urged  at  the  birth  of  every  child. 
Such  a  general  application  is  not  desirable,  since  it 
might  do  harm  in  unsuitable  cases ;  but  it  should  be  borne 
in  mind  and  resorted  to  whenever  there  is  a  probability 
that  the  mother  is  infected  with  gonorrhea. 

The  importance  of  this  matter  may  be  appreciated 
when  it  is  remembered  that  a  large  proportion  of  all  causes 
of  blindness  operate  only  in  adult  life  or  old  age,  while 
this  entails  blindness  from  infancy.  Even  when  there 
seems  no  chance  of  infection,  the  appearance  of  redness 
or  discharge  in  an  infant's  eyes  should  at  once  command 
the  attention  of  those  in  charge  of  it. 

Prognosis. — In  few  diseases  does  prognosis  depend  so 
much  upon  treatment.  Efficient  treatment,  begun  early 
enough,  will  save  the  eye  in  almost  all  cases  of  ophthal- 
mia neonatorum,  and  in  a  large  proportion  of  the  violent 
cases  of  gonorrheal  ophthalmia  in  adults.  If,  however, 
the  patient's  general  nutrition  and  resisting  power  are 
much  below  the  standard,  a  purulent  conjunctivitis  of 
very  moderate  severity  may  cause  general  opacity  or 
sloughing  of  the  cornea.  In  such  cases  this  is  liable  to 
occur  late.  In  otherwise  healthy  subjects,  if  the  cornea 
remain  clear  until  the  discharge  has  begun  decidedly  to 


250  PURULENT  CONJUNCTIVITIS. 

diminish,  there  is  a  very  strong  probability  that  it  will 
escape  damage.  If  the  conjunctiva  alone  is  involved, 
recovery  is  complete. 

Croupous  Conjunctivitis  (Plastic  Conjunctivitis, 
Oroupous  Ophthalmia). — In  certain  cases  commencing  as 
violent  catarrhal  or  purulent  conjunctivitis,  the  plastic 
material  thrown  out  upon  the  surface  of  the  lids,  instead 
of  being  carried  off  in  flakes  by  watery  discharge,  remains 
adherent  as  a  gray  rather  soft  layer  that  can  be  removed 
by  rubbing  or  with  the  forceps,  leaving  the  lid-surface 
red  and  bleeding  at  certain  places.  A  deposit  of  this 
kind  may  occur  in  severe  catarrhal,  acute  contagious  or 
mild  purulent  conjunctivitis.  After  some  days,  the  mem- 
brane deposited  separates  spontaneously,  leaving  the  sur- 
face of  the  conjunctiva  much  the  same  as  in  the  later 
stages  of  severe  catarrhal  inflammation. 

The  prognosis  is  rather  favorable,  deposit  is  usually 
confined  to  the  surface  of  the  lids,  and  the  cornea  rarely 
becomes  involved.  The  diagnosis  between  this  condition 
and  diphtheria  of  the  conjunctiva  will  be  considered 
under  the  latter  heading. 

The  treatment  should  include  the  cleansing  and 
general  measures  appropriate  for  a  mild  case  of  purulent 
conjunctivitis.  But  cold  is  to  be  avoided,  and  hot  appli- 
cations used  instead.  The  membranous  deposit  should 
be  left  undisturbed,  and  applications  of  silver  nitrate 
should  not  be  tried  until  the  false  membrane  has  dis- 
appeared. 

Diphtheria  of  the  Conjunctiva  (Diphtheritic  Con- 
junctivitis.}— When  on  everting  the  lids  in  a  case  of  com- 
mencing conjunctivitis,  one  finds  parts  of  their  inner  sur- 
face pale  gray,  infiltrated  with  rigid  material  that  strongly 
resists  the  manipulation  of  turning  the  lids,  and  the  sub- 
conjunctival  tissue  all  infiltrated,  diphtheria  of  the  con- 
junctiva must  be  suspected,  although  it  is  a  rare  disease. 

Symptoms  and  Course. — In  such  a  case  the  lids  are 
tense,  greatly  swollen,  and  are  very  much  more  rigid 
than  they  would  be  from  the  same  amount  of  swelling  in 
connection  with  purulent  conjunctivitis.  It  may  be  quite 


DISEASES  OF  THE  CONJUNCTIVA.  251 

impossible  to  evert  them.  The  paler  areas  of  the  con- 
junctiva mark  the  greatest  infiltration  and  shutting  off 
of  blood-supply.  While  the  surface  of  the  conjunctiva 
may  be  covered  with  a  false  membrane  similar  to  that 
which  forms  on  the  tonsils,  this  may  be  quite  absent ; 
the  fibrinous  exudate  being  situated  within  the  tissues. 

As  the  case  progresses,  the  whole  lid  may  become  the 
seat  of  the  rigid  infiltration,  which  may  extend  to  the 
ocular  conjunctiva.  The  eye  is  painful,  the  lids  hot  and 
red.  For  several  days  the  rigid  infiltration  continues, 
then  it  begins  to  soften,  and  the  affected  tissue  is  very 
apt  to  slough.  The  discharge  is  at  first  watery,  later 
becoming  turbid  with  fibrin  and  effused  blood,  and  puru- 
lent or  mucopurulent  in  the  stage  of  softening.  The 
local  process  is  accompanied  by  fever  and  general  depres- 
sion, such  as  mark  the  course  of  diphtheria  elsewhere. 

The  cornea  is  apt  to  become  affected  early,  and  to 
break  down  rapidly  and  be  partially  or  totally  destroyed. 
The  sloughing  of  the  lids  is  liable  to  cause  adhesions 
between  them  and  the  eyeball  (symblepharon). 

Cases  occur  in  which  the  firm  infiltration  of  the  lids  is 
entirely  absent,  the  symptoms  being  in  the  main  those  of 
catarrhal  conjunctivitis.  But  the  cornea  rapidly  breaks 
down,  and  the  microscope  shows  the  presence  of  the 
Klebs-Lofflcr  bacillus. 

Diagnosis. — The  recognition  of  typical  diphtheria  of 
the  conjunctiva  should  not  be  difficult.  The  rigidity  of 
the  lids  in  excess  of  that  ordinarily  noticed,  with  the 
same  amount  of  swelling,  and  the  gray  patches  of  stran- 
gulated tissue,  which  may  run , together  and  include  the 
whole  surface  of  the  conjunctiva  up  to  the  corneal  mar- 
gin, are  unlike  anything  seen  in  purulent  or  catarrhal 
conjunctivitis.  As  compared  with  croupous  conjuncti- 
vitis, the  condition  is  entirely  distinct.  In  croupous  con- 
junctivitis the  membrane  is  situated  upon  the  surface, 
somewhat  like  the  membrane  of  diphtheria  in  the  phar- 
ynx, while  in  diphtheria  of  the  conjunctiva  there  may  be 
no  membrane  upon  the  surface,  or  it  is  less  noticeable 
than  the  rigidity  of  the  deeper  tissues.  In  general  the 


252  DIPHTHERIA   OF  THE  CONJUNCTIVA. 

diagnosis  is  to  be  established  by  finding  of  the  Klebs- 
Loffler  bacillus ;  but  it  should  be  remembered  that  the 
so-called  xerosis  bacillus,  which  may  very  generally  be 
obtained  from  the  normal  conjunctiva  (and  which  prob- 
ably has  no  connection  with  xerosis)  resembles  so  closely 
the  true  diphtheria  bacillus  that  they  cannot  be  certainly 
distinguished  except  by  culture  experiments  and  their 
effects  on  the  lower  animals. 

Treatment. — Diphtheria  of  the  conjunctiva  is  to  be 
recognized  as  essentially  the  same  disease  as  diphtheria 
of  the  pharynx  or  larynx,  and  is  to  receive  the  same 
general  treatment.  It  is  of  the  highest  importance  that 
it  should  be  promptly  recognized,  and  treated  by  full 
injections  of  the  diphtheria  antitoxin,  repeated  at  inter- 
vals of  not  more  than  sixteen  hours  (Standish).  The 
results  of  this  line  of  treatment  applied  early  have  been 
almost  universally  satisfactory,  and  its  importance  over- 
shadows that  of  all  local  remedies.  Locally  cold  may  be 
applied,  if  swelling  of  the  lids  is  great,  the  patches  of 
gray,  rigid  infiltration  small  and  few,  and  the  cornea  not 
infected.  If,  however,  much  of  the  tissue  is  being  stran- 
gulated by  excessive  fibrinous  infiltration,  or  the  general 
condition  of  the  patient  is  one  of  depression,  or  the  cornea 
shows  signs  of  infiltration,  cold  is  to  be  avoided,  and  hot 
applications  made  as  described  for  purulent  conjunctivitis. 
In  any  case,  the  cold  should  be  limited  to  the  first  day  of 
the  attack ;  and  subsequently,  heat  continuously  applied 
to  favor  the  softening  of  the  lids  with  the  least  possible 
sloughing  of  tissue.  Careful  cleansing  of  the  conjunctiva 
is  important.  After  the  process  of  softening,  a  solution 
of  silver  nitrate  may  be  applied,  at  first  very  cautiously, 
to  the  inner  surface  of  the  lids.  If  only  one  eye  is  in- 
volved, the  other  should  be  carefully  protected  from 
infection,  as  in  purulent  conjunctivitis.  During  the 
attack,  and  subsequently,  such  general  remedies  as 
tincture  of  the  chlorid  of  iron,  free  stimulation  wifrh 
alcohol,  and  the  use  of  strychnia,  will  be  indicated. 

Prognosis. — The  chance  of  saving  an  eye  affected 
with  the  disease  depends  largely  on  the  prompt  resort  to 


DISEASES  OF  THE  CONJUNCTIVA.  253 

the  use  of  the  antitoxin.  Without  it  a  very  large  propor- 
tion of  eyes  have  been  destroyed  by  the  sloughing  of  the 
cornea.  Under  its  use,  nearly  all  reported  cases  have 
terminated  in  recovery. 

Chronic  Membranous  Conjunctivitis. — Rare  cases 
occur,  chiefly  among  children,  in  which  with  some  swell- 
ing and  slight  conjunctival  discharge,  there  are  found,  on 
everting  the  lids,  extensive  patches  of  grayish  or  whitish, 
tough,  firmly  adherent  membrane,  the  removal  of  which 
leaves  a  raw  bleeding  surface.  There  may  be  no  great 
interference  with  the  use  of  the  eye ;  which,  except  for 
the  swelling  of  the  lid,  would  look  normal.  This  condi- 
tion may  continue  for  months,  or  even  years,  without 
material  change.  The  removal  of  the  membrane  is 
promptly  followed  by  its  renewal.  Sometimes  but  one 
eye  is  involved ;  but  both  are  liable  to  become  aifected. 
In  connection  with  this  condition,  there  arise  acute  exacer- 
bations, in  which  the  cornea  may  slough  and  the  eye  be 
lost.  The  connection  of  this  condition  with  acute  diph- 
theria is  uncertain.  Repeated  examinations  have  some- 
times failed  to  discover  the  Klebs-Loffler  bacilli ;  and 
in  other  cases  they  were  only  discovered  during  acute 
exacerbations.  No  treatment  has  been  found  to  cut  short 
the  disease  or  greatly  influence  its  course. 

Chronic  Catarrhal  Conjunctivitis.  —  Repeated 
attacks  of  acute  catarrhal  conjunctivitis,  or  the  persistent 
action  of  influences  that  tend  to  cause  acute  conjunctival 
inflammation,  as  eye-strain,  habitual  exposure  to  irritant 
dust  or  vapors,  or  artificial  heat,  chronic  disease  of  the 
lacrimal  passages  with  regurgitation  of  mucopurulent 
discharge  into  the  conjunctiva,  are  among  its  common 
causes. 

Symptoms  and  Varieties. — Chronic  catarrhal  con- 
junctivitis affects  chiefly  the  palpebral  portions  of  the 
conjunctiva,  extending  in  bad  cases  or  acute  exacerba- 
tions to  the  ocular  portion.  These  exacerbations  arise 
from  whatever  increases  the  hyperemia  of  the  parts. 
The  surface  may  be  slightly  reddened  and  roughened,  by 
the  enlargement  of  the  papilla?,  constituting  the  so-called 


254        CHRONIC  CATARRH AL  CONJUNCTIVITIS. 

"granulated  lids,"  which  are  something  very  different 
from  granular  conjunctivitis.  The  discharge  consists  of 
only  a  few  shreds  of  mucopurulent  matter,  which  may 
collect  at  the  canthtis ;  or,  during  the  closure  of  the  lids 
at  night  it  may,  by  drying  on  the  lashes,  glue  them 
together  so  that  some  force  is  required  to  open  the  eyes 
in  the  morning.  The  eyeball  may  be  perfectly  normal 
in  appearance  or  may  present  only  a  few  dilated  veins. 

A  common  form  of  disease  aifects  old  people  who  live 
in  bad  hygienic  surroundings.  There  is  little  or  no  dis- 
charge, and  the  entire  surface  of  the  lids  remains  smooth. 
The  epithelial  layer  is  apparently  thickened,  so  that  the 
conjunctival  surface  of  the  lid  presents  the  appearance  of 
purplish-red  covered  with  a  gray  film.  This  form  of  the 
disease  is  attended  with  a  great  deal  of  smarting  and 
burning,  on  account  of  which  the  patient  usually  seeks 
relief,  and  is  willing  to  undergo  prolonged  treatment. 

Diagnosis. — The  diagnosis  of  chronic  catarrhal  inflam- 
mation of  the  conjunctiva  is  to  be  made  from  the  history 
of  the  case,  the  appearances  above  described  and  the 
absence  of  symptoms  characterizing  other  forms  of  chronic 
conjunctival  disease,  which  will  be  referred  to  in  connec- 
tion with  those  diseases. 

Treatment  consists  of:  First,  removal  of  the  cause,  if 
this  be  possible  ;  as  the  relief  of  the  eye-strain  by  glasses, 
change  of  occupation  or  residence  when  the  disease  is  due 
to  habitual  exposure  to  some  irritant;  or  removal  of 
lacrimal  obstruction.  If  there  is  considerable  thickening 
of  the  lids,  or  discharge,  they  may  occasionally  be  bathed 
for  two  or  three  minutes  with  very  hot  water.  The 
local  applications  should  include  some  rather  strong 
astringent,  as  a  solution  of  silver  nitrate  ^  to  1  per  cent., 
a  solution  of  tannin  in  glycerin,  or  crystal  of  alum, 
applied  to  the  surface  of  the  everted  lid.  Where  such 
applications  cannot  be  made  at  intervals  of  two  or  three 
days,  a  solution  of  zinc  sulphate  j  to  ^  per  cent,  may  be 
given  to  be  dropped  into  the  eye  once  or  twice  daily.  In 
a  very  mild  case  boric  acid  solution  may  answer  best. 
For  decidedly  chronic  cases,  either  alone  or  in  connection 


DISEASES  OF  THE  CONJUNCTIVA.  255 

with  the  astringents  mentioned,  an  ointment  of  yellow 
oxid  of  mercury  should  be  used  once  daily. 

Prognosis. — This  disease  can  last  indefinitely ;  and 
often  the  cure  will  depend  entirely  upon  the  removal  of 
the  cause.  If,  however,  the  condition  has  lasted  for 
years,  some  of  its  effects  are  likely  to  persist  in  spite  of 
any  treatment.  The  chronic  conjunctivitis  of  old  people, 
attended  by  smarting,  is  commonly  not  completely  cur- 
able ;  but  is  capable  of  alleviation,  which  is  usually  highly 
appreciated. 

Parinaud's  conjunctivitis  is  a  rare  disease  character- 
ized by  a  severe  onset,  great  swelling  of  the  lids,  polypoid 
granulations  of  the  conjunctiva,  involvement  of  the  neigh- 
boring lymphatic  glands,  and  ultimate  recovery.  It 
affects  commonly  but  one  eye,  attacks  children  and  adults, 
and  the  onset  is  attended  with  slight  rigors  and  severe 
general  depression.  The  disturbance  and  swelling  of  the 
pre-auricular,  sub-maxillary,  and  cervical  lymphatic 
glands  of  the  affected  side  are  marked ;  and  sometimes 
these  go  on  to  suppuration.  If  the  granulations  are  not 
very  numerous,  they  may  be  cut  off  and  their  bases  cauter- 
ized. Other  treatment  seems  to  have  but  little  effect,  but 
the  case  goes  slowly  on  to  recovery. 

Vernal  Conjunctivitis  (Spring  Catarrh,  Fruhjahr 
Catarrh). — This  is  a  rather  rare  disease,  affecting  children 
and  young  persons,  recurring  year  after  year,  during  the 
summer.  The  more  marked  cases  begin  in  the  spring 
and  last  until  cool  weather  in  autumn.  After  some  years 
the  attacks  become  less  severe,  and  finally  may  cease 
altogether. 

Symptoms  and  Course. — The  inner  surface  of  the  lid 
presents  a  general  redness,  with  enlargement  of  the 
papillae.  In  typical  cases  there  is  the  appearance  of  the 
blueish  white  film,  like  a  thin  layer  of  milk,  spread  over 
the  conjunctival  surface.  Both  eyes  are  affected,  though 
sometimes  one  more  than  the  other.  In  a  considerable 
portion  of  the  cases  the  ocular  conjunctiva  appears  nor- 
mal. In  typical  cases,  however,  it  presents  hyperemia, 
and  at  the  corneal  margin  a  plicated  thickening  and  in- 


256  VERNAL   CONJUNCTIVITIS. 

creased  redness,  which  may  be  pigmented.  There  is  con- 
siderable smarting  pain  and  increased  lacrimation  during 
the  height  of  the  attack. 

Treatment. — No  plan  of  medicinal  treatment,  either 
general  or  local,  can  be  relied  on  to  cut  short  the  disease. 
The  local  application  of  astringents  sometimes  diminishes 
the  discomfort.  Randolph  reports  the  best  results  from 
an  ointment  of  salicylic  acid  in  lanolin,  2  to  15  per  cent., 
rubbed  well  into  the  conjunctiva  daily,  after  securing 
local  anesthesia  with  cocain.  But  the  chief  remedy  is 
removal  if  possible  during  the  hot  season  from  the  city 
to  the  country,  or  to  the  mountains  or  seashore.  Some- 
thing may  often  be  done  for  children  by  attention  to  their 
clothing,  an  excess  of  which  may  have  caused  the  attack. 
An  ointment  of  yellow  oxid  of  mercury  as  used  for  phlyc- 
tenular  disease  has  proven  fairly  satisfactory  as  a  local 
application.  Very  dilute  acetic  acid,  1  part  of  the  dilute 
acid  to  250  of  water,  has  been  recommended  for  the 
relief  of  the  smarting. 

Prognosis. — The  prognosis  as  to  ultimate  recovery 
without  permanent  damage  is  good,  but  the  duration  of 
the  attack  cannot  be  foretold,  and  there  is  a  liability  to 
recurrence  of  the  trouble  year  after  year. 

Follicular  conjunctivitis  is  a  form  of  subacute  or 
chronic  conjunctivitis  in  which  pale,  translucent  follicles, 
or  masses  are  found  in  the  folds  of  the  conjunctiva  where 
it  passes  from  the  globe  onto  the  lid.  The  appearance 
of  the  follicles  is  very  noticeable  in  comparison  with  the 
hyperemia  present.  The  condition  is  essentially  a  catar- 
rhal  conjunctivitis,  and  amenable  to  the  same  treatment. 
But  the  presence  of  the  enlarged  follicles  justifies  its 
separate  classification  to  emphasize  its  difference  from 
trachoma. 

Trachoma  (Granular  Conjunctivitis,  True  Granular 
Lids,  Chronic  Blennorrhea,  Chronic  Ophthalmia,  Egyptian 
Ophthalmia)  is  a  specific  inflammatory  disease  of  the  con- 
junctiva, arising  from  infection,  and  running  an  extremely 
chronic  course.  It  is  probably  due  to  a  small  cliplococcus, 
which  is  found  in  the  granulations  and  sometimes  in  the 


DISEASES  OF  THE  CONJUNCTIVA.  257 

secretions.  It  arises  under  bad  hygienic  conditions,  and 
where  people  are  crowded  together,  as  in  the  steerage- 
passage  across  the  ocean,  in  barracks,  schools,  and  orphan 
asylums.  From  such  centers  of  contagion  it  extends 
in  communities  that  present  favorable  conditions  for  it 
by  reason  of  overcrowding  or  lack  of  cleanliness.  Race 
exerts  an  important  influence,  it  being  common  among 
the  Italians,  Irish,  and  people  of  Northern  Europe,  and 
very  rare  among  American  negroes.  Climate,  and  prob- 
ably the  amount  and  character  of  the  dust  in  the  atmos- 
phere have  some  influence  upon  it.  But  it  is  not,  as  some 
have  supposed,  only  found  at  low  altitudes. 

Symptoms  and  Course. — Many  cases  arise  insidiously, 
so  that  the  patient  does  not  recognize  that  there  is  any- 
thing the  matter  until  the  case  is  well  developed.  In  a 
majority,  however,  the  first  effect  of  the  specific  virus  is 
an  inflammation  that  cannot  be  distinguished  from  acute 
catarrhal,  or  purulent  conjunctivitis.  Such  inflammation, 
however,  declares  its  character  by  running  a  slower 
course,  with  gradual  thickening  of  the  conjunctiva  and 
deeper  tissues,  moderate  mucopuruleut  discharge,  and  the 
progressive  development  of  the  characteristic  granula- 
tions. These  granulations  vary  in  size,  from  the  smallest 
perceptible  to  three  or  four  mm.  in  diameter.  They  are 
more  or  less  deeply  embedded,  but  mostly  protrude  some- 
what. Their  appearance  is  illustrated  in  Fig.  87. 


FIG.  87. — Trachoma,  showing  the  trachoma-granules  on  the  everted  upper 
lid,  with  pannus  extending  on  the  upper  part  of  the  cornea  to  below  the  mar- 
gin of  the  pupil. 

They  have  the  gray  color  and  translucency  of  sago 
grains,  when  partly  soaked  in  water.     They  are  largest 
where  the  conjunctiva  passes  from  the  eyeball  to  the  lids. 
17 


258  TRACHOMA. 

The  entire  surface  of  the  lids,  particularly  of  the  upper, 
may  be  studded  with  them ;  but  they  are  never  massed 
together  and  mutually  compressed,  like  the  papillary 
granulations  seen  after  purulent  conjunctivitis  (see  Fig. 
86).  They  are  much  larger  than  the  papillae  of  chronic 
conjunctivitis,  and  their  presence  in  other  parts  than  the 
retrotarsal  folds  distinguishes  them  from  the  enlarged 
follicles  of  follicular  catarrh. 

As  the  entire  surface  of  the  lids  becomes  seriously  in- 
volved and  considerably  roughened,  corneal  complica- 
tions are  apt  to  arise,  endangering  the  sight.  These  are 
described  under  the  headings  of  pannus,  corneal  ulcers, 
and  opacities  (Chapter  X). 

The  full  development  of  typical  granulations  and  cor- 
neal complications  usually  requires  several  weeks  or 
months.  When  this  stage  has  been  reached  the  case  may 
remain  without  essential  change  for  years.  In  a  majority 
of  cases  the  trachoma  granules,  which  consist  of  masses 
of  leukocytes,  undergo  partial  organization  into  connective 
tissue.  The  contraction  of  this  tissue  may  stop  the  for- 
mation of  granules,  but  always  leads  to  deformity  of  the 
lids.  Ultimately  all  appearance  of  the  granules  may  van- 
ish and  the  entire  surface  of  the  lids  become  smooth, 
presenting  the  appearance  of  chronic  catarrhal  conjuncti- 
vitis, and  only  the  sequels  of  the  disease,  lid-deformity, 
conjunctival  contraction,  and  corneal  irregularity,  may 
remain.  These  will  remain,  however,  throughout  life. 

The  above  description  refers  to  a  typical  case  of  tra- 
choma. Each  feature  included  in  it  may  at  some  time 
be  lacking.  In  some  cases  that  appear,  from  association, 
to  be  due  to  trachoma  virus,  the  granules  never  develop, 
the  case  running  the  course  of  a  chronic  catarrhal  con- 
junctivitis with  considerable  discharge,  and  perhaps  with 
involvement  of  the  cornea.  In  a  considerable  portion  of 
cases,  the  disease,  although  characterized  by  well-devel- 
oped trachoma  granules,  seems  to  give  little  or  no  dis- 
comfort a  large  part  of  the  time,  the  patient  only  noticing 
its  existence  during  the  exacerbations  of  acute  inflamma- 
tion, which  occur  at  intervals.  Occasionally  these  cases 


DISEASES  OF  THE  CONJUNCTIVA.  259 

go  on  to  an  enormous,  almost  horny  thickening  of  the  lids, 
before  seeking  treatment.  In  a  few  patients  without 
efficient  treatment,  and  in  a  large  proportion  under  such 
treatment,  the  disease  runs  its  course  in  a  few  months 
without  involving  the  cornea,  and  leaves  but  very  slight 
contraction  of  the  conjunctiva,  or  deformity  of  the  lids. 
In  other  cases  the  inflammation  is  intense,  the  discharge 
excessive,  the  cornea  becomes  involved  early,  and  only 
prompt  and  vigorous  treatment  can  prevent  complete 
blindness.  In  some  cases  the  trachoma  granules,  although 
present,  are  deeply  embedded  beneath  the  thickened 
opaque  conjunctiva,  or  in  the  masses  of  fibrous  tissue 
that  have  developed  in  the  lid,  so  that  they  are  not  seen. 

Diagnosis. — The  presence  of  the  typical  trachoma 
granules  already  described  scattered  over  the  surface  of 
the  lids  is  sufficient  to  establish  the  diagnosis.  If  they 
are  confined  to  the  retrotarsal  fold,  the  case  may  be 
merely  one  of  follicular  catarrh.  Involvement  of  the 
cornea  with  a  history  of  catarrhal  conjunctivitis,  and 
marked  cicatricial  contraction,  is  also  characteristic.  In 
the  early  stage  marked  objective  changes  in  the  conjunc- 
tiva with  little  discomfort  point  towrard  trachoma.  Some- 
times the  termination  of  the  case  must  be  known  before 
a  diagnosis  can  be  arrived  at.  The  history  of  oppor- 
tunity for  infection  is  a  valuable  indication.  But  the 
patient's  statement  as  to  the  duration  of  his  trouble  is 
often  very  erroneous. 

Treatment. — In  the  early  stage,  before  the  granules 
have  developed  sufficiently  to  render  the  diagnosis  posi- 
tive, applications  of  silver  nitrate  may  be  resorted  to. 
Whenever  the  granulations  are  noticeable,  or  if  they 
exist  hidden  under  the  conjunctiva  or  in  the  thickened 
lid,  the  progress  of  recovery  will  be  hastened  by  mechani- 
cally pressing  out  the  granules.  This  may  be  done  with 
the  thumb-nails,  catching  the  thickness  of  the  lid,  or  a 
fold  of  its  inner  surface,  between  the  two  nails,  and  by 
firm  pressure  forcing  out  all  that  can  be  so  removed  from 
its  tissue.  It  is  better  done  with  some  form  of  forceps 
made  for  the  purpose.  Those  of  Prince  have  smooth 


260  TREATMENT  OF  TRACHOMA. 

fenestrated  jaws,  with  which  one  or  more  of  the  granules 
are  caught,  and  by  a  pull  of  the  forceps  pressed  out.  But 
the  writer  prefers  the  roller-forceps  of  Knapp,  by  which 
the  contents  of  the  granules  are  pressed  out,  as  water  is 
pressed  out  of  clothing  by  a  wringing  machine  (see 
Chap.  XIX). 

In  a  few  cases  the  mechanical  removal  of  the  granular 
contents  from  the  lids  may  be  followed  by  full  recovery 
without  further  treatment ;  but  in  the  large  majority  of 
cases  it  only  hastens  the  recovery,  which  must  be  brought 
about  by  astringent  applications,  faithfully  continued  as 
long  as  necessary.  Removal  of  the  trachoma  granules  has 
been  effected  by  free  incisions,  scraping,  or  brushing, 
(grattage  and  brassage) ;  but  these  methods  are  not  more 
efficient  than  expression,  and  are  more  likely  to  be  fol- 
lowed by  excessive  cicatricial  changes. 

For  cases  in  which  the  lids  contain  little  or  none  of  the 
granular  material,  the  application  of  astringents  is  to  be 
relied  upon. 

These  must  be  thoroughly  applied  to  the  whole  affected 
surface  of  the  everted  lids,  any  excess  being  washed  away 
or  neutralized.  Among  such  applications,  that  of  the 
crystal  of  copper  sulphate  (bluestone)  has  been  found 
most  beneficial.  At  the  height  of  an  attack  it  may  be 
applied  every  day  ;  but  usually  every  second  or  third  day 
is  sufficient.  Next  to  it  in  general  usefulness  the  writer 
would  place  the  solution  of  tannin  in  glycerin.  This 
latter  application  is  more  useful  when  the  discharge  is 
slight  and  the  conjunctiva  comparatively  smooth.  Where 
the  thickening  is  chiefly  in  the  conjunctiva  and  the  dis- 
charge considerable,  solutions  of  silver  nitrate  arc  most 
beneficial.  A  solution  of  iodin  in  glycerin  or  in  liquid 
petrolatum,  applied  to  the  everted  lids  every  day  or  two, 
has  a  very  decided  curative  effect.  The  application  of  a 
strong  solution  of  mercuric  chlorid  has  been  highly 
recommended.  A  solution  of  1  :  500,  or  even  stronger, 
may  be  brushed  over  the  conjunctiva,  and  all  excess 
washed  away  ;  but  such  an  application  is  quite  painful. 
Excision  of  the  affected  retrotarsal  fold  and  of  the  tarsus 


DISEASES  OF  THE  CONJUNCTIVA.  261 

has  been  practiced,  and  is  claimed  to  hasten  the  cure  in 
some  cases. 

In  addition  to  the  strong  applications  mentioned,  the 
eyes  should  be  kept  cleansed,  when  a  noticeable  discharge 
is  present,  with  a  solution  of  boric  acid,  or  a  weak  solution 
of  sublimate  or  formaldehyde.  In  the  more  chronic  cases, 
the  correction  of  marked  errors  of  refraction  may  exert 
a  beneficial  influence ;  and  in  any  case  the  avoidance  of 
dust  or  of  a  smoke-laden  atmosphere  will  be  helpful.  An 
important  part  of  the  treatment,  is  that  of  the  alterations 
produced  in  the  cornea  and  the  lids.  These  will  be  con- 
sidered under  their  respective  headings.  But  if  the  pal- 
pebral  fissure  is  markedly  contracted,  interfering  consid- 
erably with  the  eversion  of  the  lids  for  treatment,  a 
canthotomy,  or  better  a  canthoplasty,  should  be  done  to 
increase  the  efficiency  of  local  applications.  If  displace- 
ment of  the  lashes  is  such  as  to  cause  them  to  rub  against 
the  cornea  or  conjunctiva,  their  restoration  to  normal 
position  may  be  a  necessary  part  of  the  treatment. 

Prognosis. — In  a  large  portion  of  cases  the  treatment 
needs  to  be  continued  for  months,  or  even  for  several 
years ;  and  in  any  but  the  most  acute  and  favorable  cases 
there  will  remain  very  noticeable  cicatricial  changes  in 
the  conjunctiva  and  lids.  It  is  impossible  at  the  outset 
of  any  case  to  tell  when  treatment  can  be  safely  sus- 
pended, and  its  premature  suspension  may  be  followed  by 
complete  relapse.  Occasionally  cases  are  permanently 
cured  and  in  a  few  weeks,  oftener  in  a  few  months ;  but 
many  cases  may  need  occasional  applications  for  years. 
A  safe  prognosis  will  be  absolutely  non-committal. 

Phlyctenular  Conjunctivitis  (Phlyctenular  Kerato- 
conjunctivitis,  Phlyctenular  Ophthalmia,  Strumous  or 
Scrofulous  Ophthalmia,  Conjunctivitis  Lymphaticci). — This 
affection  is  excited  by  many  of  the  causes  of  catarrhal 
conjunctivitis.  It  occurs  chiefly  in  children  with  an 
underlying  tendency  to  catarrhal  affections  of  all  mucous 
surfaces,  eczematous  eruptions,  and  glandular  enlarge- 
ments. 

It  is  characterized  by   chronic  hyperemia  of  the  pal- 


262  PHLYCTENULAR  CONJUNCTIVITIS. 

pebral  conjunctiva ;  and  recurrent  exacerbations,  includ- 
ing the  development  of  phlyctenules  on  the  ocular 
conjunctiva  and  cornea  and  occasionally  on  the  palpebral 
conjunctiva,  with  symptoms  of  acute  conjunctivitis. 

Symptoms  and  Course. — The  phlyctenular  attack 
usually  begins  with  irritability  of  the  eyes,  photophobia, 
and  excessive  lacrimation.  In  one  or  two  days  there  develop 
on  some  portion  of  the  ocular  conjunctiva,  usually  the 
corneal  margin,  or  upon  the  cornea  itself,  vesicular  eleva- 
tions with  a  red  and  swollen  base.  The  vesicle,  or  phlyc- 
tenule,  quickly  becomes  an  ulcer,  the  contents  escaping. 
The  deeper  swelling  causes  the  ulcer  to  appear  elevated 
above  the  general  surface.  The  redness  which  is  most 
intense  in  a  limited  sector  of  the  conjunctiva,  running 
forward  to  the  phlyctenule  (see  Fig.  17),  continues  to  in- 
crease for  two  or  three  days  and  becomes  general.  The 
discharge  is  slight  and  is  washed  away  in  the  excessive 
flow  of  tears.  In  a  severe  attack,  a  crop  of  phlyctenules 
may  be  scattered  all  around  the  margin  of  the  cornea. 
At  the  height  of  the  attack,  the  whole  of  the  conjunctiva 
may  be  hyperemic  and  thickened.  In  a  few  days  this 
general  redness  subsides,  but  the  sectors  of  enlarged  ves- 
sels running  out  to  the  region  of  the  phlyctenules,  con- 
tinue some  days  longer.  These  with  the  swollen  tissue 
of  the  phlyctenules,  gradually  return  to  normal,  the 
whole  attack  lasting  from  one  to  three  weeks,  unless  pro- 
longed by  the  formation  of  a  corneal  ulcer.  The  photo- 
phobia is  often  so  severe  that  the  child  buries  its  head  in 
a  pillow  and  refuses  to  use  its  eyes,  even  in  a  darkened 
room. 

Before  the  termination  of  the  first  attack  a  second  may 
begin,  so  that  the  eye  is  kept  continually  red  and  painful  ; 
or  there  may  be  an  interval  in  which  the  eye  is  appar- 
ently normal  before  the  trouble  recurs.  During  the 
interval  the  inner  surface  of  the  lids  will  be  found 
hyperemic,  the  visible  vessels  being  larger  and  more 
numerous  than  normal,  and  there  may  be  a  slight  con- 
junctival  discharge  causing  adhesion  of  the  lids  in  the 
morning.  In  the  attack  the  conjunctiva  is  always  in- 


DISEASES  OF  THE  CONJUNCTIVA.  263 

volved,  but  the  danger  of  the  prolonged  inflammation 
and  damage  to  the  sight  lies  in  the  involvement  of  the 
cornea  (see  Chap.  X).  The  conjunctival  aifeetion  will,  in 
time,  if  not  aggravated  by  injudicious  applications,  end 
in  recovery,  with  restoration  of  a  smooth  but  sometimes 
slightly  contracted  membrane. 

Diagnosis. — The  diagnosis  from  acute  catarrhal  con- 
junctivitis rests  on :  the  distribution  of  the  hyperemia 
(see  p.  61),  the  occurrence  of  the  phlyctenules  or  the 
ulcers  that  succeed  them,  the  excessive  photophobia  and 
lacrimation,  the  history  of  previous  attacks,  and  the  pres- 
ence of  enlarged  vessels  in  normally  transparent  tissue  on 
the  inner  surface  of  the  lids.  To  make  a  satisfactory 
examination  of  a  child's  eyes,  it  will  often  be  needful  to 
put  it  in  the  position  for  making  applications  to  the  con- 
junctiva, and  sometimes  to  use  a  lid  elevator.  The 
habitual  tight  closure  of  the  lids  frequently  gives  rise  to 
a  macerated  condition  of  the  skin  near  the  outer  canthus, 
with  the  formation  of  fissures  or  rhagades  radiating  from 
the  outer  canthus. 

Treatment. — Every  case  of  phlyctenular  conjunctivitis 
requires  the  careful  consideration  of  the  general  nutrition, 
and  of  local  influences  outside  of  the  eye  and  its  imme- 
diate appendages.  A  proportion  of  cases  will  recover 
without  other  treatment  if  placed  on  proper  diet.  This 
should  consist  largely  of  milk  and  well-cooked  farinaceous 
foods.  The  strict  prohibition  of  tea  or  coffee,  and  fried 
foods  is  very  important ;  and  the  restriction  of  sweetmeats, 
cakes,  and  candy,  which  should  be  taken  only  at  the  close 
of  a  meal  and  with  plenty  of  water.  Care  of  the  diet 
may  be  supplemented  by  the  administration  of  remedies 
addressed  to  the  alimentary  canal,  as  small  doses  of 
calomel,  followed  by  some  other  laxative,  and  the  digest- 
ants  where  indicated. 

Next  in  importance  is  the  careful  treatment  of  the 
nasal  passages.  These  will  often  present  a  chronic  thick- 
ening and  hyperemia  of  the  mucous  membrane,  which, 
although  often  but  another  expression  of  the  general  dis- 
order, especially  hinders  the  return  of  the  conjunctiva  to 


264  PHLYCTENULAR  CONJUNCTIVITIS. 

normal,  and  should  receive  appropriate  local  treatment, 
including  cleansing,  alterative  applications,  as  iodin,  com- 
pound tincture  of  benzoin,  etc.,  and  spraying  with  liquid 
petrolatum. 

Where  the  patient  presents  distinct  evidence  of  glandu- 
lar involvement  and  anemia,  general  tonics,  especially 
syrup  of  iodid  of  iron,  or  hydriodic  acid,  with  quinin, 
should  be  given.  Local  treatment  to  the  eye  is  not  less 
important.  Of  greatest  benefit  are  applications  of  the 
ointment  of  yellow  oxid  of  mercury,  commencing  with 
a  weak  preparation,  and  increasing  its  strength  until  the 
application  causes  some  little  smarting.  The  ointment  is 
to  be  applied  once  daily,  usually  at  bed-time,  by  drawing 
down  the  lower  lid  and  placing  within  it  a  piece  the  size 
of  a  grain  of  rice  or  slightly  larger.  The  eye  is  then 
closed  and  the  closed  lids  are  rubbed  over  the  globe,  until 
the  drug  has  been  diffused  to  every  part  of  the  conjunc- 
tiva; and  the  portion  escaping  between  the  lids  is  rubbed 
well  into  their  margins. 

If  the  inflammation  of  the  conjunctiva  is  severe,  appli- 
cations of  a  solution  of  tannin  in  glycerin  should  be  made 
every  two  or  three  days  to  the  everted  lids.  The  use  of 
the  mercuric  oxid  must  be  continued  during  the  intervals 
between  the  attacks,  and  occasion lly  for  weeks  or  months 
after  the  eyes  seem  free  from  inflammation.  In  the  more 
severe  chronic  cases  it  is  well,  also,  to  continue  the  appli- 
cation of  glycerin  and  tannin.  Where  the  photophobia 
is  severe,  the  fissures  in  the  skin  of  the  lids  near  the  outer 
canthus  greatly  aggravate  the  trouble.  These  should  be 
touched  either  with  tannin  in  glycerin,  or  with  1  or  2  per 
cent,  solution  of  silver  nitrate.  The  making  of  applica- 
tions to  the  lids  in  these  cases  is  often  somewhat  difficult ; 
and  the  means  for  assuring  efficiency  in  applications  to 
the  eyes  of  children,  mentioned  in  Chapter  XVIII, 
must  be  resorted  to. 

Prognosis. — The  individual  attack  of  phlyctenular 
disease  is  usually  recovered  from  within  two  or  three 
weeks ;  but  subsequent  attacks  are  extremely  probable. 


DISEASES  OF  THE  CONJUNCTIVA.  265 

Permanent  damage  always  depends  on  the  lesions  of  the 
cornea. 

Pterygium. — Pterygium  is  an  extension  of  conjuncti- 
val  and  subconjunctival  tissue  upon  the  cornea,  triangu- 
lar in  shape,  with  the  apex  toward  the  center  of  the 
cornea,  and  the  base  at  the  corneal  margin,  usually 
toward  the  nasal  side.  Its  appearance  and  usual  situa- 
tion are  shown  in  Fig.  88. 


FIG.  88.— Pterygium  extending  over  the  margin  of  the  pupil. 

Symptoms  and  Course. — Pterygium  sometimes  fol- 
lows corneal  ulcers.  It  also  follows  traumatism,  and 
probably  arises  from  the  presence  of  minute  foreign 
bodies,  and  chronic  irritations  without  previous  loss  of 
corneal  tissue.  In  some  way  it  seems  to  be  largely  in- 
fluenced by  climatic  or  local  conditions,  being  much  more 
common  in  some  places  than  in  others.  It  is  slowly 
progressive,  often  for  a  long  time ;  but  finally  it  becomes 
stationary  usually  before  it  has  encroached  much  upon 
the  area  of  the  pupil.  The  conjunctiva  covering  it  is 
generally  quite  vascular  and  supported  by  a  thick  mass  of 
subconjunctival  tissue,  and  this  vascularity  and  thicken- 
ing extend  upon  the  sclera  to  the  region  of  the  caruncle. 

It  is  probable  that  the  thick  developing  mass  of 
connective  tissue  underneath  it  is  a  factor  in  the 
drawing  forward  of  the  conjunctiva  upon  the  cornea. 
The  vascularity  and  prominence  of  the  pterygium  vary 
from  time  to  time,  being  greatest  during  the  period  of 
growth  and  often  much  diminished  at  later  stages  when 
the  growth  seems  to  undergo  partial  atrophy.  It  is 
loosely  connected  with  the  cornea,  which,  after  its  re- 
moval, may  be  found  normal  except  for  the  absence  of 
the  epithelium  and  a  slight  disturbance  and  haziness  of 


266  PTERYGIUM. 

its  superfical  layers ;  the  portion  overlying  the  sclera  is, 
however,  pretty  firmly  connected  with  it.  It  may  occur 
in  early  adult  life,  but  is  more  common  after  middle  age. 

Pterygium  is  not  painful,  and  so  long  as  it  does  not 
approach  the  region  of  the  pupil,  is  only  unpleasant 
because  of  its  appearance.  If  it  encroaches  upon  the 
pupil,  sight  is  impaired ;  and  often  before  the  growth 
reaches  the  pupillary  margin,  an  area  of  astigmatism 
which  advances  before  it,  may  impair  vision,  particularly 
when  the  pupil  is  somewhat  dilated.  When  very  exten- 
sive it  may  cause  limitation  of  the  movements  of  the  eye- 
ball and  diplopia  in  the  peripheral  portions  of  the  field 
of  fixation. 

Diagnosis. — Ptergyium  is  to  be  distinguished  from 
superficial  vascular  keratitis  by  its  appearance  of  lying 
upon  the  cornea,  having  a  margin  distinctly  elevated 
above  the  corneal  surface.  It  differs  from  dermoid  of 
the  corneal  margin  in  its  greater  vascularity,  in  the  dis- 
tribution of  its  vessels,  and  in  its  triangular  shape  as 
contrasted  with  the  rounded  or  ovoid  form  of  the  der- 
moid. From  pinguecula  it  differs  in  extending  on  the 
cornea,  which  pinguecula  never  does  (see  Fig.  89). 

Treatment. — If  small  and  not  progressive,  removal  is 
not  to  be  urged.  During  periods  of  excessive  hyperemia, 
the  treatment  may  be  that  of  a  mild  subacute  conjuncti- 
vitis. If  progressive,  and  particularly  if  already  ap- 
proaching the  pupillary  margin,  it  should  be  removed. 
This  may  be  done  by  excision  or  transplantation. 
Ligation,  formally  practiced,  is  not  to  be  advised.  The 
advantage  of  transplantation  is  that,  should  the  pterygium 
again  develop,  requiring  a  second  operation,  the  parts  are 
left  in  a  more  favorable  condition  for  it.  After  excisions, 
the  loss  of  substance  makes  a  second  operation  more 
difficult,  and  more  liable  to  cause  impairment  of  the  ocular 
movements.  For  a  very  large  pterygium,  the  most 
effective  method  is  to  excise  it  and  by  an  epithelial  skin- 
graft,  or,  better,  a  graft  from  the  mucous  membrane  of  the 
lip,  to  cover  the  denuded  portion  of  the  sclera.  The  after- 
treatment  includes  regular  cleansing  of  the  conjunctiva 


DISEASES  OF  THE  CONJUNCTIVA.  267 

and  the  removal  of  the  sutures,  usually  on  the  second 
or  third  day.  There  is  at  first  some  swelling,  but  this 
rapidly  subsides.  Small  pterygia  may  be  checked  by 
electrolysis,  or  the  apex  of  the  growth  may  be  destroyed 
by  the  galvanic  or  actual  cautery. 

Prognosis. — In  a  large  proportion  of  cases  pterygium, 
if  left  to  itself,  never  interferes  seriously  with  the  vision, 
and  operation  is  only  of  benefit  in  that  it  removes  an 
unsightly  deformity.  The  rate  of  development  or  its 
ultimate  size  cannot  be  surely  predicted.  The  security 
from  recurrence  depends  much  on  the  completeness  of  the 
removal  of  the  mass  of  connective  tissue  overlying  the 
solera. 

Pinguectila  is  a  yellowish  elevation  of  the  conjunc- 
tiva to  the  nasal  side  of  the  cornea,  caused  by  an  accumu- 
lation of  connective  tissue  and  fat.  It  is  shown  in  Fig. 
89.  When  slightly  inflamed,  it  may  become  prominent, 


FIG.  89.— Pinguecula  with  large  conjunctival  vessels  to  the  iiasal  side  of  the 

cornea. 

and  cause  disfigurement.     It  may  develop  into  pterygium, 
but  usually  it  requires  no  treatment. 

Pemphigus,  in  very  rare  cases,  affects  the  conjunc- 
tiva, isolated  spots  become  affected,  quickly  lose  their 
epithelium,  and  undergo  shrinking ;  then  other  portions 
of  the  membrane  undergo  the  same  changes  until  the 
conjunctival  sac  is  obliterated,  the  sight  lost,  and  the  lids 
bound  down  closely  to  the  globe.  The  disease  occurs  in 
cachectic  patients,  who  suffer  from  pemphigus  affecting  the 
skin.  Hygienic  measures  and  internal  remedies,  especially 
arsenic,  are  chiefly  to  be  relied  on.  Locally,  soothing 
collyria  may  be  used,  and  if  the  disease  is  once  thoroughly 
checked,  skin-grafting  into  the  conjunctival  sac  may  be 
resorted  to. 


268  CHRONIC  DISORDERS. 

Xerosis,  or  essential  shrinking  of  the  conjunctiva,  has 
been  reported  as  occurring  independently  of  pemphigus, 
and  occasionally  as  the  final  stage  of  that  disease.  The 
cornea  participates  in  the  process,  becomes  dry  and  opaque, 
and  sight  is  lost. 

Tuberculosis  and  I/upus  of  the  Conjunctiva.— 
Tubercular  disease  of  the  conjunctiva  is  rare,  yet  occa- 
sionally cases  occur.  The  course  of  the  affection  is  very 
chronic,  and  its  general  characters  resemble  those  of 
trachoma ;  but  it  lacks  the  characteristic  trachoma-gran- 
ules, is  less  liable  to  involve  the  cornea,  and  is  more  regu- 
lar in  its  course.  The  palpebral  conjunctiva  is  chiefly 
affected,  and  the  lids  appear  swollen  and  firm  to  touch. 
The  infiltration  as  seen  from  the  conjunctival  surface, 
while  nodular,  is  red  or  yellowish-gray,  and  does  not 
resemble  the  sago-grains  of  trachoma.  The  surface  often 
becomes  ulcerated,  which  is  not  the  case  with  trachoma ; 
and  the  lymphatic  glands  in  front  of  the  ear  are  apt  to 
be  affected  early. 

Where  lupus  extends  from  the  skin  of  the  lid  into  the 
conjunctival  sac,  the  portion  of  the  ulcer  lying  in  the 
conjunctiva  presents  much  the  appearance  of  tuberculosis 
primary  in  that  membrane.  The  diagnosis  may  be  com- 
pleted by  the  discovery  of  the  tubercle  bacilli  in  a  piece 
of  excised  tissue. 

Treatment. — Tubercular  disease  in  this  situation  should 
be  treated  ty  complete  excision,  or  very  thorough  cur- 
etting, under  general  anesthesia,  with  the  application  of 
strong  carbolic  acid,  or  similar  caustic,  to  the  raw  surface 
obtained ;  and  subsequent  dressing  with  iodoform.  The 
specific  treatment  with  tuberculin  and  similar  prepara- 
tions has  sometimes  proved  beneficial. 

Syphilis  of  the  conjunctiva  may  occur  at  any 
stage  of  the  disease.  The  primary  sore  occurs  most  often 
near  the  inner  canthus,  or  in  the  lower  cul-de-sac.  It 
presents  an  ulcer  with  a  hard  base  and  glandular  involve- 
ment, lasts  several  weeks,  and  is  comparatively  painless. 
In  connection  with  skin-eruptions  there  may  be  a  chronic 
catarrhal  conjunctivitis  not  influenced  by  local  treatment 


DISEASES  OF  THE  CONJUNCTIVA.  269 

or  the  removal  of  ordinary  causes ;  but  curable  by  anti- 
syphilitic  treatment.  Gumma  is  very  rare ;  but  chronic 
ulcer  with  great  infiltration  sometimes  occurs  in  late 
syphilis,  and  may  be  mistaken  for  cancer. 

Amyloid  degeneration  of  the  conjunctiva  is  -a  rare 
condition,  characterized  by  the  deposits  of  amyloid 
material  in  the  conjunctiva  and  lids.  It  is  usually  asso- 
ciated with  trachoma,  but  may  occur  independently.  The 
lids  are  thickened  and  rigid,  the  exudate  being  yellow  in 
color  and  occurring  in  larger  masses  than  the  trachoma- 
granules,  being  continuous  beneath  the  whole  surface. 
There  is  usually  a  history  of  previous  disease,  and  absence 
of  the  discharge  and  symptoms  of  acute  inflammation, 
which  mark  the  progress  of  trachoma. 

Symblepharon. — If  in  any  way  the  conjunctiva  is 
destroyed  on  both  the  eyeball  and  the  inner  surface  of 
the  lids,  especially  if  such  destruction  involves  the  retro- 
tarsal  fold,  the  resulting  cicatrix  is  liable  to  bind  the  lid 
to  the  eyeball  (see  Fig.  90).  This  most  frequently  occurs 


FIG.  90.— Symblepharon. 

after  burning  of  the  conjunctiva  with  hot  metal,  lime,  or 
other  caustics,  the  lower  part  of  the  conjunctiva  being 
usually  affected.  Sometimes  the  adhesion  extends  onto 
the  cornea,  and  may  even  cover  the  whole  of  it,  prevent- 
ing useful  vision.  Even  when  this  does  not  occur,  the  limit- 
ation of  the  movement  of  the  eyeball  may  cause  annoying 


270  SYMBLEPHARON. 

diplopia.  The  connection  between  the  eyeball  and  the 
lids  is  brought  out  most  strongly  by  drawing  the  lid  away 
from  the  globe,  when  it  is  rotated  away  from  the  adhesion. 
Such  adhesions  continue  to  contract  and  become  more 
annoying,  often  for  many  months,  and  the  prognosis  with 
reference  to  them  should  be  guarded. 

Treatment. — Much  ingenuity  has  been  expended  to 
prevent  the  formation  of  such  adhesions  between  the  lids 
and  eyeball,  by  repeatedly  breaking  them  up,  or  con- 
tinuously wearing  some  form  of  metal  shield.  But  little 
ultimate  benefit  has  resulted  from  such  measures.  Where 
the  connecting  bridge  of  the  conjunctiva  is  entirely 
isolated,  so  that  a  probe  can  be  passed  beneath  it  (anterior 
symblepharon\  the  division  of  the  bridge  gives  complete 
relief.  If  the  fold  extends  to  the  conjunctival  cul-de-sac 
(posterior  symblepharon),  but  is  comparatively  narrow,  it 
may  be  possible  to  make  a  permanent  opening  behind  it, 
by  wearing  for  six  weeks  or  longer  a  piece  of  lead  wire 
passed  through  its  base  ;  or  it  may  be  divided  near  its  base, 
and  the  conjunctiva  from  opposite  sides  brought  together, 
making  an  isolated  bridge  of  the  adhesion,  which  can 
subsequently  be  divided.  In  a  majority  of  cases  requir- 
ing operation  such  methods  are  inapplicable,  and  the  best 
result  is  to  be  obtained  by  freely  dissecting  the  joining 
fold  away  from  the  eyeball,  allowing  what  there  is  of  it 
to  go  as  epithelial  covering  for  the  lid,  and  covering  the 
denuded  area  of  the  globe  by  mucous-  or  skin-grafts.  The 
mere  division  of  a  symblepharon  gives  only  temporary 
benefit. 

Edema  has  been  referred  to  in  connection  with  con- 
junctival inflammation.  It  may,  however,  occur  apart 
from  this,  in  cases  of  paralysis  of  the  ocular  muscles,  as 
an  effect  of  certain  drugs,  particularly  potassium  iodid 
and  quinia,  or  as  a  variety  of  so-called  angioncurotic 
edema.  Emphysema  of  the  subconjunetival  tissue 
may  occur  from  injury  in  the  nose. 

Ecchymosis. — Small  hemorrhages  into  the  conjunc- 
tiva and  deeper  tissues  mark  the  course  of  all  severe 
conjunctival  inflammation,  and  especially  that  of  acute 


DISEASES  OF  THE  CONJUNCTIVA.  271 

contagious  conjunctivitis.  More  extensive  extravasations 
of  blood  occur  by  the  rupture  of  blood-vessels  during 
coughing,  vomiting,  etc.  in  purpuric  conditions,  from 
general  vascular  degeneration  sometimes  preceding  hem- 
orrhage into  the  brain  or  other  vital  organ,  and  even 
without  any  discoverable  cause.  Such  extravasations 
require  no  treatment,  undergoing  complete  absorption, 
without  causing  unpleasant  symptoms  other  than  the 
disfigurement. 

Tumors. — Benign  tumors  occasionally  occur  in  the 
conjunctiva.  Clear  cysts  form  especially  in  the  lower 
cul-de-sac.  Angiomas  involve  the  lids,  and  are  con- 
sidered in  that  connection.  Dermoids  usually  involve 
the  corneal  margin.  Fibromas  occur  as  small  polypoid 
growths,  and  osteoma  has  been  met  with.  Papillo- 
mas  grow  in  masses  with  a  structure  and  surface  resem- 
bling cauliflower.  They  start  usually  from  near  the  inner 
canthus,  but  may  extend  so  as  to  hide  the  cornea.  They 
recur  unless  very  completely  removed.  Lipoma  is  seen 
on  the  outer  portion  of  the  eyeball.  Cysticercus  occurs 
rarely.  On  the  West  Coast  of  Africa  the  "  eye-worm," 
flaria,  is  acquired.  It  may  be  seen  at  times  rapidly 
moving  under  the  conjunctiva.  These  tumors  and  para- 
sites are  to  be  treated  by  removal. 

Epithdiorna  may  start  from  the  conjunctiva!  margin  of 
the  cornea ;  in  this  situation  it  is  sometimes  pigmented. 
Sarcoma  arises  from  exposed  portions  of  the  conjunctiva 
and  is  usually  pigmented.  Such  tumors  of  the  conjunc- 
tiva usually  develop  very  slowly.  Their  early  removal 
without  sacrificing  the  eyeball  may  be  tried,  but  if  there 
be  doubt  as  to  the  completeness  of  such  removal,  extirpa- 
tion of  the  eye,  with  the  growth,  is  necessary. 

Concretions  in  the  Conjunctiva. — On  everting 
the  lids  one  may  often  detect  one  or  more  yellowish 
masses,  the  size  of  a  pin-head,  lying  in  the  conjunctiva. 
These  are  accumulations,  in  small  divisions  of  the  Meibo- 
mian  glands,  or  in  the  other  glands  of  the  mucous  mem- 
brane. They  are  at  first  of  cheesy  consistence,  and  may 
remain  a  long  time  without  making  any  disturbance, 


272          CONCRETIONS  IN  THE  CONJUNCTIVA. 

although  patients  not  rarely  discover  them,  and  ascribe 
to  their  presence  symptoms  due  to  other  causes.  They 
may,  however,  undergo  calcareous  changes ;  and,  by 
thinning  of  the  membrane  over  them,  come  to  act  very 
much  as  foreign  bodies  in  the  conjunct! val  sac,  causing 
irritation,  redness  and  discomfort.  If  this  occurs,  each 
offending  mass  should  be  removed.  It  is  readily  turned 
out  of  its  bed  with  the  point  of  a  needle. 

Burns  of  the  conjunctiva  may  occur,  from  hot 
steam,  ashes,  powder,  other  explosives,  or  drops  of  molten 
metal.  Similar  injuries  may  be  caused  by  contact  with 
some  caustic,  such  as  strong  mineral  acids  and  alkalies, 
and  especially  lime.  Whether  the  injury  be  by  heat  or  a 
chemical  caustic,  the  affected  tissue  will  be  found  rather 
pale  and  opaque,  and  edema  of  the  adjoining  tissues 
quickly  develops.  The  danger  of  such  injuries  lies  in 
the  involvement  of  the  cornea  and  in  the  liability  of  their 
causing  symblepharon.  The  resulting  inflammation, 
unless  very  severe,  is  usually  limited  to  the  immediate 
seat  of  the  injury,  which  is  the  conjunctiva  of  the  eyeball, 
except  when  molten  metal  or  caustic  has  run  into  the 
lower  cul-de-sac,  involving  also  the  palpebral  portion  of 
the  membrane.  A  like  distribution  of  the  redness  and 
swelling  characterizes  the  resulting  conjunctivitis. 

Occasionally  a  sharp  attack  of  conjunctivitis  is  caused 
by  sunburn.  The  hyperemia  is  most  severe  in  the  por- 
tion of  the  conjunctiva  exposed  to  the  sun's  rays ;  but 
there  may  be  general  swelling  of  the  membrane,  and 
acute  burning  and  smarting. 

Treatment. — As  promptly  as  possible  any  foreign  par- 
ticle remaining  at  the  seat  of  injury  should  be  removed, 
and  a  chemical  caustic  thoroughly  neutralized.  The 
stronger  acids  may  be  removed  and  neutralized  by  thor- 
oughly washing  with  a  solution  of  borax,  and  the  alkalies 
by  washing  with  milk  or  sweet  oil.  The  action  of  lime 
may  be  checked  by  dropping  sweet  oil  or  a  solution  of 
cane  sugar  into  the  eye.  Particles  of  lime  become  firmly 
united  to  the  eschars  they  cause,  but  their  removal  should 
be  accomplished.  After  this  the  eye  may  be  treated  with 


DISEASES  OF  THE  CONJUNCTIVA.  273 

borax  and  boric  acid  solution,  to  thoroughly  cleanse  it, 
and  a  drop  of  liquid  petrolatum  instilled  to  protect  the 
exposed  nerve-endings.  Eschars  should  not  be  disturbed 
any  more  than  is  necessary  for  removing  foreign  particles, 
or  neutralizing  the  caustic  causing  them. 

Other  injuries  and  foreign  bodies  are  considered 
in  Chapter  XVII. 

Discoloration  of  the  ocular  conjunctiva  by  pigment 
deposits  is  common  in  the  colored  race ;  and  occasionally 
occurs  in  the  white.  A  more  general  and  uniform  brown- 
ish discoloration  is  caused  by  long  continued  applications 
of  silver  nitrate.  In  Addison's  disease  and  in  various 
forms  of  anemia,  the  conjunctiva  is  transparent,  and  the 
sclera  seen  through  it,  pearly  white.  This  is  to  a  consid- 
erable extent  normal  in  young  children,  the  conjunctiva 
and  subconjunctival  tissue  becoming  thickened,  more 
vascular  and  yellower  with  age. 

Diseases  of  the  Caruncle. — Inflammation  of  the 
caruncle  occurs  with  conjunctivitis.  It  is  marked  by 
redness  and  swelling.  It  is  particularly  noticeable  in 
conjunctivitis  from  eye-strain,  when  the  other  evidences 
of  conjunctivitis  may  be  slight  and  easily  overlooked. 
Occasionally  the  caruncle  is  the  seat  of  abscess.  Chronic 
non-inflammatory  enlargement  is  called  encanthis.  Occa- 
sionally numerous  short  hairs  spring  from  the  caruncle. 
They  may  be  so  directed  as  to  cause  redness  and  irritation 
of  other  parts. 

BIBLIOGRAPHY. 

Diseases  of  the  Conjunctiva.     J.  E  Weeks,  "American  Text-book." 
Diseases  of  the  Conjunctiva  and  Sclera.     S.  M.  Burnett.     "  System 

of  Diseases  of  the  Eye." 
Diseases  and   Injuries   of  the  Conjunctiva.     J.  H.  Thompson,  216 

pp.,  Hudson-Kimberly  Co.,  Kansas  City. 
Ophthalmic  Bacteriology.     H.  Gifford,  "  Archives  of  Ophthalmol.," 

Nov.,  1898. 

Pneumococcus  Conjunctivitis.     H.  Gifford,   ''  Archives  of  Ophthal- 
mol.,"   July,    1896;   J.  E.  Weeks,  "Ophthal.  Kecord,"  June, 

1897. 
Bacteriology  of  Acute  Conjunctivitis.     V.  Morax  and  G.  W.  Beach, 

"Archives  of  Ophthalmology,"  Jan..  1896. 
Clinical   and   Bacteriological   Aspects  of  Acute  Conjunctivitis.     V. 

Morax  and  P.  Petit.  "Ophthal.  Kev.,"  Feb.,  1898. 

18 


274  DISEASES  OF  THE  CONJUNCTIVA. 

Diagnosis  of  Diphtheria  of  the  Conjunctiva.  S.  Stephenson,  "  Brit- 
ish Med.  Jour.,"  June  18,  1898'. 

Diphtheritic  Conjunctivitis.  Myles  Standish,  "Trans.  Amer.  Oph- 
thalmol.  Soc.,"  1897. 

Etiological  Relations  of  Nasal  Disease  to  Affections  of  the  Eye.  H. 
Cradle,  "Trans.  Sec.  onOphthal.  Amer.  Med.  Assoc.,"  1892.  • 

Prevention  of  Blindness  from  Ophthalmia  Neonatorum.  L.  Howe, 
"Trans.  Amer.  Ophthalmol.  Soc.,"  1897  and  1898. 

Influence  of  General  Nutrition  upon  Ophthalmia  of  the  New  Born. 
H.  V.  Wiirdemann,  "  Annals  of  Ophthalmol."  Jan.,  1896. 

School  Ophthalmia.  Jonathan  Hutchinson,  "Trans.  Ophthalmol. 
Soc.  of  United  Kingdom,"  Feb.  and  Mar.,  1894. 

The  Palpebral  Form  of  Spring  Catarrh.  PI.  Cradle,  "Arch,  of  Oph- 
thalmol.," Oct.,  1895. 

The  Tarsal  Form  of  Spring  Catarrh.  A.  Darier,  "Annals  of  Oph- 
thalmol.," July,  1897. 

Trachoma.  Its  Etiologic  Organism.  E.  F.  Snydacker,  "Jour. 
Amer.  Med.  Assoc.,"  Feb.  4,  1899. 

Surgical  Treatment  of  Trachoma.  S.  Stephenson,  "Ophthalmic 
Review,"  Jan.,  1893. 

Treatment  of  Trachoma.  "  Trans.  Section  on  Ophthalmol.  Amer. 
Med.  Assoc.,"  1897. 

Episcleritis  Periodioa  Fugax.  E.  Fuchs,  "  Brit.  Med.  Jour.,"  Oct. 
19,1895;  "Ophthal.  Review,"  Feb.,  1896. 

Ophthalmia  Nodosa.  J.  B.  Lawford,  "Trans.  Ophthalmol.  Soc. 
of  the  United  Kingdom,"  June,  1895;  Geo.  Knapp,  "Amer. 
Jour,  of  Ophthalmol.,"  Aug.,  1897. 

Parinaud's  Conjunctivitis,  Five  Cases.  H.  Gifford,  "Amer.  Jour, 
of  Ophthalmol.,"  July,  1898. 

Rheumatic  and  Gouty  A  flections  of  the  Conjunctiva.  R.  A.  Reeve, 
"Trans.  Congr.  Amer.  Phys.  and  Surgeons,"  1897. 

Angio-Neurotic  Oedema  of  the  Conjunctiva.  G.  M.  Black,  "  Oph- 
thalmic Review,"  Oct.,  1895. 

Pinguecula  and  Pterygium.  E.  Fuchs,  "Ophthalmic  Review"  Mar. 
and  Sep.,  1892. 

Pterygium  and  Its  Treatment.  II.  Lopez,  "  Arch,  of  Ophthalmol.," 
May,  1898. 

Epithelial  Xerosis  of  the  Conjunctiva.  S.  Stephenson,  "Trans,  of 
the  Ophthalmol.  Soc.  of  the  United  Kingdom,'"  Jan.,  1898. 

Tuberculosis  of  the  Conjunctiva.  J.  W.  H.  Eyre,  "Trans.  Oph- 
thalmol. Soc.  of  the'  United  Kingdom,"  July,  1897. 

Primary  Sarcoma  of  the  Lacrymal  Caruncle.  C.  A.  Vensoy, 
"Archives  of  Ophthalmol.,"' April,  1897;  S.  Snell,  "  Archives 
of  Ophthalmol.,"  July,  1897. 

Filaria  in  or  Near  the  Eye.  Argyll  Robertson,  "Trans.  Oph.  Soc. 
United  Kingdom,"  Oct.,  1894.  Mar.,  1895,  and  June,  1897;  F. 
M.  Wilson,  "Trans.  Amer.  Ophthalmol.  Soc.,"  1890. 


DISEASES  OF  THE  CORNEA.  275 

CHAPTER  X. 

DISEASES  OF  THE  CORNEA  AND  SOLERA. 

General  Conditions  Regarding  the  Cornea. — 

The  cornea  is  composed  chiefly  of  a  tissue  closely  allied 
to  white  connective  tissue,  is  normally  devoid  of  blood- 
vessels, and  is  covered  with  a  layer  of  conjunctival  epi- 
thelium. With  the  latter  point  may  be  associated  its 
liability  to  involvement  in  conjunctival  disease.  Its  lack 
of  vessels  causes  the  location  of  hyperemia  connected 
with  morbid  processes  affecting  it,  to  be  in  the  zone 
immediately  surrounding  it,  where  ramify  the  vessels 
from  which  its  nutriment  is  drawn.  This  separation  of 
the  tissue  from  its  base  of  supplies  causes  its  particular 
liability  to  undergo  ulceration  and  to  slough.  Corneal 
inflammations  are  liable  to  run  the  chronic  course  that 
inflammations  do  in  white  fibrous  tissues  in  other  parts 
of  the  body.  Its  transparency  depends  upon  a  delicate 
balance  of  nutritive  processes,  likely  to  be  disturbed  by 
any  departure  from  the  normal ;  and  rarely  entirely 
regained  when  any  considerable  portion  of  its  tissue  is 
replaced  by  the  new-formed  connective  tissue  of  a  scar. 
Many  of  the  inflammations  in  it  are  characterized  by  loss 
of  substance  giving  rise  to  corneal  ulcers.  Where  this 
does  not  occur,  or  after  the  replacement  of  tissue  lost,  the 
prominent  symptom  is  the  opacity. 

Finally  the  corneal  tissue  is  compelled  to  sustain  the 
outward  pressure  of  the  intra-ocular  fluids,  and  when 
softened  by  disease  it  gives  way  before  this  pressure, 
causing  changes  of  shape  and  permanent  disturbances  of 
its  nutrition.  And  whenever  corneal  inflammation  lasts 
for  any  considerable  time  there  is  a  tendency  to  extension 
of  the  blood-vessels  upon  and  into  the  corneal  tissue. 
These  vessels  continue  to  develop  until  the  inflammation 
has  passed  its  height,  and  the  process  of  repair  is  well 
started  ;  then  they  diminish  in  size  and  number,  and  may 
entirely  disappear. 


276  CORNEAL   ULCERS. 


CORNEAL  ULCERS. 

Simple  Ulcer  of  the  Cornea  (Non-suppurating 
Ulcer,  Ulcerous  Keratitis).  —  This  condition  consists 
essentially  in  loss  of  a  portion  of  the  corneal  epithe- 
lium, and  of  the  true  corneal  tissue  beneath.  It  may  arise 
from  traumatism,  either  external  or  that  due  to  a  rough 
or  deformed  lid ;  or  from  a  local  inflammatory  process, 
attended  with  disintegration  of  tissue,  as  in  phlyctenular 
keratitis,  or  herpes  of  the  cornea ;  or  as  a  complication 
in  acute  conjunctivitis. 

Symptoms  and  Course. — The  loss  of  corneal  sub- 
stance is  to  be  detected  by  the  irregularity  or  break  that 
it  causes  in  the  reflection  from  the  cornea  of  a  window 
or  lamp-flame  when  this  is  reflected  from  the  part  in- 
volved. It  is  commonly  attended  with  pain  of  a  burn- 
ing, smarting  or  aching  character,  dread  of  exposure  to 
light  and  air,  and  excessive  lacrimation. 

An  ulcer  may  properly  be  classed  as  simple  when  not 
surrounded  by  markedly  infiltrated  and  disintegrated 
tissue,  when  it  does  not  tend  to  materially  extend  after 
its  first  formation,  and  is  not  complicated  by  perforation 
or  other  accident.  In  its  earliest  stage  its  surface  lacks 
the  polish  of  the  normal  cornea.  But  as  soon  as  the  pro- 
cess of  repair  is  fairly  started  the  bottom  of  the  ulcer 
appears  glazed  over,  giving  as  bright  a  reflection  as  does 
the  cornea  around  it,  although  its  surface  may  be  quite 
noticeably  depressed. 

During  the  process  of  repair,  the  excavation  fills  up 
until  the  surface  of  the  ulcer  becomes  continuous  with 
that  of  the  surrounding  cornea.  This  is  accomplished  by 
the  formation  of  new  tissue  beneath  the  epithelial  layer, 
which  new  tissue  is  at  first  not  perfectly  transparent,  but 
rather  gray  in  color ;  so  that  the  opacity  attending  such 
an  ulcer  tends  to  increase  throughout  the  period  of  heal- 
ing, and  is  most  noticeable  several  days,  or  sometimes 
weeks,  after  pain  and  other  evidences  of  inflammation 
have  disappeared. 

The   existence   of   an   ulcer   is   quickly   followed   by 


DISEASES  OF  THE  CORNEA.  277 

hyperemia  of  the  nutritive  vessels  of  the  cornea,  causing 
a  red  or  pink  pericorneal  zone.  If  the  ulcer  be  situ- 
ated near  the  center  of  the  cornea  this  zone  will  be  almost 
equally  pronounced  all  around  the  corneal  margin.  If 
the  ulcer  be  close  to  the  corneal  margin,  the  portion 
of  the  pericorneal  zone  adjoining  it  will  be  chiefly,  or 
alone  reddened ;  and  as  the  ulcer  heals,  the  redness  will 
disappear  last  in  this  locality.  Pain  is  usually  consider- 
able, and  in  some  forms,  especially  where  there  is  a  broad 
shallow  excavation  as  by  an  infant's  finger  nail,  or  in  the 
ulcers  that  occur  with  chronic  conjunctivitis  in  old  people, 
pain  may  be  very  severe.  It  is  generally  accompanied 
by  photophobia  and  excessive  lacrimation. 

Diagnosis. — The  careful  inspection  of  the  reflex  from 
every  part  of  the  corneal  surface  will  usually  reveal  the 
loss  of  substance.  If  there  is  difficulty  about  discovering 
it  in  this  way,  a  drop  of  a  solution  of  fluorescin  will  stain 
the  cornea  green  over  the  whole  ulcerated  surface  reveal- 
ing exactly  its  extent.  It  is  sometimes  difficult  to  dis- 
tinguish an  old  opacity  of  the  cornea  from  one  due  to 
recent  infiltration.  On  this  account  the  inspection  should 
be  made  by  daylight,  or  white  artificial  light,  to  recog- 
nize the  true  color  of  the  opacity. 

Treatment. — If  a  corneal  ulcer  be  due  to  traumatism, 
any  foreign  particles  remaining  in  it  should  be  removed. 
The  tendency  to  recover  is  strong,  and,  beyond  cleansing, 
little  active  treatment  is  required.  Still  every  ulcer, 
however  simple  it  may  appear,  is  in  danger  of  becoming 
complicated  by  infection,  and  of  extending  so  as  to  cause 
perforation  of  the  cornea,  and,  therefore,  should  be  closely 
watched.  To  guard  against  infection,  the  eye  should  be 
cleansed  with  an  unirritating  solution,  such  as  one  of 
boric  acid  or  sodium  chloric!,  and  kept  closed  between 
the  times  of  making  applications  to  it,  by  a  very  light 
dressing. 

A  mydriatic,  such  as  atropin  or  duboisin,  should  be  in- 
stilled two  or  three  times  a  day  if  there  is  decided  redness 
and  irritation.  Pain  if  not  completely  relieved  by  the 
mydriatic,  may  be  met  by  applications  of  heat,  either 


278  SIMPLE   ULCER. 

bathing  with  hot  water,  or  the  more  continued  applica- 
tion of  dry  heat.  Often  the  proper  treatment  of  the 
condition,  either  constitutional  or  local,  which  causes  the 
ulcer,  will  be  more  important  than  the  treatment  of  the 
ulcer  itself.  Rest  and  a  tonic  treatment  are  usually  in- 
dicated. 

Suppurating  Ulcer  (Perforating  Ulcer,  Infecting  or 
Sloughing  Ulcer,  Ring  Ulcer,  Creeping  Ulcer,  or  Ser- 
piginous  Ulcer). — In  this  section  are  considered  lesions 
of  varied  character  and  due  to  many  distinct  causes,  but 
all  characterized  by  a  tendency  of  the  ulcer  to  extend  by 
the  disintegration  of  neighboring  tissue.  The  direction 
in  which  such  extension  occurs  depends  somewhat  on  the 
cause  of  the  lesion  and  has  given  rise  to  classifications 
into  varieties  according  to  the  form  assumed.  But  while 
these  different  varieties  vary  somewhat  in  their  clinical 
aspects,  in  their  essential  dangers  and  treatment,  they  are 
largely  similar.  For  one  who  has  large  clinical  exper- 
ience and  fair  acquaintance  with  the  subject,  each  of  the 
terms  at  the  head  of  this  section  may  serve  to  present  a 
distinct  clinical  picture.  But  for  the  student  or  practi- 
tioner of  moderate  experience  in  dealing  with  corneal 
ulcers,  the  essential  facts  will  be  best  grasped  by  a 
general  description  of  those  features  which  all  varie- 
ties have  in  common,  with  brief  reference  to  specific 
differences. 

Symptoms,  Varieties,  and  Course. — Suppurating 
ulcer  may  start  from  an  injury,  from  an  apparently  simple 
ulcer,  from  the  opening  of  a  corneal  abscess,  or  from  the 
sloughing  of  injured  or  severely  infiltrated  tissue.  It 
presents  the  symptoms  of  simple  ulcer,  but  often  of  greater 
severity  and  more  rapid  development.  The  floor  of  the 
ulcer  (when  wiped  dry)  is  devoid  of  luster,  and  is  infil- 
trated. The  tissue  at  the  margins  is  also  clouded  or 
opaque  with  infiltration.  The  infiltration  may  be  gray 
or  distinctly  yellow,  the  latter  color  indicating  a  stronger 
tendency  to  pus  formation  and  rapid  breaking  down  of 
tissue. 

The  direction  in  which  the  infiltration  is  most  marked 


DISEASES  OF  THE  CORNEA.  279 

is  that  toward  which  the  ulcer  is  most  likely  to  extend. 
If  unchecked,  the  infiltration  and  disintegration  of  tissue 
may  rapidly  involve  large  parts  of  the  cornea  (sloughing 
ulcer),  may  extend  to  deeper  layers  of  the  cornea,  leading 
to  perforation  (perforating  ulcer) ;  may  extend  along  the 
corneal  margin  until  it  forms  a  complete  girdle  around 
the  cornea  (ring  ulcer).  It  may  extend  rapidly  by  an 
opaque  yellow  margin,  first  in  one  direction,  then  in  a 
slightly  different  direction,  or  even  in  an  opposite  direc- 
tion, by  a  breaking  down  of  the  corneal  tissue  on  one 
side  of  it,  usually  with  some  undermining  of  the  surface, 
but  without  much  tendency  to  penetrate  the  deeper 
layers  and  perforate  the  cornea  (serpent,  or  creeping 
ulcer).  So  long  as  the  ulcer  has  an  opaque,  sharply  ex- 
cavated, or  undermined  margin,  and  the  adjoining  tissue 
remains  devoid  of  vessels,  the  process  is  extending. 
When  the  tissue  adjoining  the  ulcer  is  found  clear,  or  has 
become  distinctly  vascular,  the  extension  of  the  ulcer  is 
checked.  When  the  floor  of  the  ulcer  (after  wiping  it 
with  absorbent  cotton)  is  found  smooth  and  reflecting  like 
the  surface  of  the  cornea,  the  process  of  repair  is  fairly 
begun. 

Perforation  is  the  great  danger  of  the  corneal  ulcer, 
being  followed  by  the  most  disastrous  effects.  No  corneal 
ulcer  can  be  regarded  as  free  from  this  danger  so  long  as 
it  is  extending  or  is  opposed  by  inadequate  power  of 
repair.  The  thickness  of  the  normal  cornea  is  usually 
about  1  millimeter,  but  a  cornea  previously  diseased,  or 
even  a  normal  cornea,  may  be  much  thinner  than  this,  so 
that  perforation  may  occur  when  not  expected.  On  the 
other  hand,  some  forms  of  corneal  ulcer  have  swollen 
margins,  so  that  with  a  depth  as  great  as  the  normal 
thickness  of  the  cornea,  no  perforation  may  occur. 

The  deepest  layers  of  the  cornea,  and  particularly  the 
membrane  of  Descemet,  usually  resist  the  process  of  dis- 
integration longer  than  the  more  superficial  portions,  so 
that  after  the  ulcer  has  reached  them  its  further  progress 
may  be  checked.  When,  however,  the  floor  of  the  ulcer 
is  wide,  the  thin  layer  of  tissue  forming  it  is  unable  to 


280 


SUPPURATING   ULCER. 


resist  the  intra-ocular  tension,  and  may  be  found  bulg- 
ing into  the  ulcer,  concealing  its  real  depth,  until  the 
thinned  tissue  gives  way.  In  a  few  cases  the  disintegra- 
tion extends  quickly  to  the  deeper  layers  of  the  cornea, 
and  the  whole  thickness  of  the  membrane  separates  in  a 
single  slough.  After  the  cornea  has  been  perforated  the 
ulcer  may  continue  to  extend  until  the  cornea  has  been 
destroyed.  In  other  cases  the  process  of  repair  now  gains 
the  advantage  over  the  process  of  disintegration,  and  no 
further  extension  of  the  disease  occurs. 

With  perforation  the  contents  of  the  anterior  chamber 
escape,  and  the  iris  and  lens  are  pushed  forward  against 
the  cornea.  If  the  perforation  be 
in  front  of  it,  the  iris  commonly 
becomes  adherent  to  the  margin, 
and  the  aqueous  humor,  accumu- 
lating behind  it,  pushes  it  forward 
into  the  opening.  This  condition 
is  shown  in  Fig.  91.  In  this  situ- 
ation its  surface  quickly  becomes 
coated  with  plastic  exudate,  which 
undergoes  organization,  and  the 
mass  of  new  tissue,  with  the  altered 
iris,  forms  the  scar-tissue  that  re- 
places the  part  destroyed  in  the 
formation  of  the  ulcer.  (See  Cor- 
neal  Opacities.) 

With    the   escape   of    the   con- 
tents of  the  anterior  chamber  the 

pupil  strongly  contracts,  so  that  the  iris  is  drawn  in 
front  of  the  perforation  unless  it  be  very  small  and 
quite  central.  In  that  case  the  lens  may  be  pushed  for- 
ward and  close  the  opening.  Even  when  the  perforation 
is  in  front  of  the  iris,  the  lens-surface  may  come  in  con- 
tact with  the  cornea.  It  then  becomes  the  seat  of  plastic 
exudate,  and  the  epithelium  of  the  capsule  undergoes  pro- 
liferation, at  least,  in  young  patients.  The  exudate  closing 
the  opening  in  the  cornea,  allows  the  reaecumulation  of 
the  aqueous  humor,  which  pushes  the  lens  back  from  the 


FIG.  91.— Perforating  ulcer 
of  the  cornea  with  incarce- 
ration of  the  iris  and  com- 
mencing repair. 


DISEASES  OF  THE  CORNEA.  281 

corneal  opening,  putting  the  exudate  connecting  the  lens 
and  cornea  upon  the  stretch,  and  breaking  it  and  re-estab- 
lishing the  anterior  chamber.  The  drag  upon  the  lens- 
capsule  in  this  process,  with  the  influence  of  the  exudate 
remaining  upon  it,  tends  to  establish  a  small  opacity — 
anterior  polar  cataract  (see  Chap.  XIV). 

Causes. — To  the  causes  sufficient  to  produce  simple 
ulcer  of  the  cornea,  are  always  added  for  the  production 
of  suppurating  ulcer,  local  infection  and  insufficient  re- 
sisting power  on  the  part  of  the  tissue.  The  infective 
agent  is  usually  one  of  the  pyogenic  organisms,  which 
may  be  derived  from  the  discharge  of  a  purulent  conjunc- 
tivitis, or  the  regurgitation  from  a  chronically  inflamed 
lacrimal  sac.  Or  it  may  be  the  pneumococcus  which 
Holden  has  connected  with  serpent  ulcer,  tending  to 
extend  between  the  corneal  layers ;  or  the  diplobacillus, 
or  the  diphtheria  bacillus,  or  one  of  these  with  the  pus 
cocci. 

The  deficient  resisting  power  may  be  caused  by  pres- 
sure of  severe  chemosis,  or  greatly  swollen  lids  upon  the 
pericorneal  vessels  that  furnish  the  nutritive  supply  of  the 
cornea.  It  may  be  due  to  impaired  innervation,  as  in 
paralysis  of  the  fifth  nerve,  or  with  herpes  zoster.  Or  it 
may  be  due  to  some  specific  poison  acting  upon  the  tissue 
through  the  general  circulation,  as  in  small-pox,  where 
the  cornea  is  liable  to  become  involved ;  or  to  an  impaired 
or  debased  nutritive  supply  from  general  disorders  of  the 
circulation,  or  wasting  disease.  It  may  follow  unnatural 
exposure  of  the  cornea,  and  inability  of  the  lids  and  tears 
to  keep  it  properly  cleansed,  as  by  cicatricial  destruction 
of  the  lids,  paralysis  of  the  orbicularis  muscle,  or  pushing 
forward  of  the  eyeball  in  exophthalmic  goiter,  or  orbital 
tumor. 

Diagnosis. — Besides  the  points  mentioned  as  to  the 
diagnosis  of  simple  ulcer,  in  every  case  of  corneal  sup- 
puration it  must  be  carefully  determined  which  of  the 
above  conditions  share  in  causing  the  lesion  ;  and  at  each 
visit  the  surgeon  must  try  to  ascertain  by  careful  exami- 
nation whether  the  infiltration  that  precedes  loss  of  sub- 


282  SUPPURATING    ULCER. 

stance  is  still  extending.  The  exact  organisms  of  infec- 
tion can  only  be  determined  by  careful  microscopic  and 
culture  examinations  of  the  scrapings  obtained  from  the 
surface  of  the  ulcer. 

Treatment. — In  the  earlier  stages  the  important  thing 
is  to  check  the  progress  of  the  ulcer.  This  will  be 
effected  by  combating  the  causes,  and  by  disinfection  of 
the  ulcer  itself.  Thus,  in  a  case  of  purulent  conjunc- 
tivitis, the  treatment  of  the  conjunctivitis  must  be  pushed 
energetically.  Where  the  infection  comes  from  regurgi- 
tation  from  the  lacrimal  sac,  the  sac  must  have  thorough 
antiseptic  treatment.  In  so  far  as  the  breaking  down  of 
the  cornea!  tissue  is  due  to  general  impairment  of  nutri- 
tion, tonics  and  stimulants  must  be  resorted  to.  If  the 
ulcer  is  of  traumatic  origin,  it  should  be  thoroughly  freed 
from  any  retained  foreign  particles. 

In  carrying  out  these  measures,  however,  care  must  be 
taken  not  to  do  injury  to  the  cornea  itself.  Thus,  in 
making  applications  of  silver  nitrate  to  the  conjunctiva 
in  a  gonorrheal  ophthalmia,  care  must  be  taken  not  to 
allow  the  solution  to  come  in  contact  with  the  cornea. 
For  the  same  reason  the  use  of  cold  is  contraindicated, 
and  hot  applications  that  will  quicken  corneal  nutrition 
are  to  be  favored. 

The  early  treatment  of  the  ulcer  itself  is  to  disinfect  it, 
and  to  prevent  reinfection.  Many  ulcers  do  better  under 
a  light  protective  bandage  that  keeps  the  eye  closed  and 
excludes  foreign  matter.  Particles  of  dust  lodging  on 
the  normal  cornea  are  promptly  wiped  away  by  the  mar- 
gin of  the  lid  and  carried  off  in  the  tears.  But  when 
there  is  loss  of  substance,  the  lid-margin  cannot  remove 
from  the  interior  of  the  ulcer  the  particles  which  may 
lodge  upon  it,  and  which,  therefore,  remain  to  increase 
irritation  and  renew  infection.  The  chief  means  of  dis- 
infection is  the  mechanical  removal  of  disintegrating 
tissue  by  curetting,  and  the  destruction  of  it  by  the  actual 
cautery.  For  ulcers  that  are  spreading  at  all  rapidly,  the 
infiltration  extending  beyond  them  into  neighboring  tis- 
sues, caustics,  like  silver  nitrate,  or  strong  solutions  of 


DISEASES  OF  THE  CORNEA.  283 

mercuric  chlorid,  have  not  sufficient  penetrating  power 
to  be  efficient. 

The  most  generally  applicable  treatment  is  thorough 
curetting  or  scraping.  This  may  be  done  with  a  spud  for 
the  removal  of  foreign  bodies  or  other  blunt  instrument. 
(See  Chapter  XIX.) 

This  operation  not  only  removes  most  of  the  infected 
and  infective  material,  but  it  also  quickens  the  flow  of 
lymph  in  the  direction  of  the  ulcer,  tending  still  further 
to  limit  infection.  It  must  be  repeated  as  often  as  the 
area  of  infiltration  is  found  to  be  extending;  sometimes 
within  twelve  hours,  usually  within  a  day,  if  repetition 
be  required  at  all. 

Where  the  case  can  be  carefully  watched  and  the  ulcer 
efficiently  scraped  as  often  as  is  necessary,  this  mode  of 
treatment  is  usually  efficient.  When,  however,  the  ulcer 
is  deep,  the  pressure  necessary  in  curetting  may  cause  the 
rupture  of  the  thinned  cornea ;  and  where  the  patient 
cannot  be  frequently  examined,  or  where  his  control  over 
the  eye  is  so  poor  that  curetting  cannot  be  thorough,  the 
actual  cautery  is  distinctly  superior. 

For  the  cauterization  of  an  ulcer,  the  corneal  cautery, 
a  probe,  or  a  steel  knitting-needle  may  be  heated  to  white 
heat  in  an  alcohol  flame ;  or  the  galvano-cautery  may  be 
employed  to  touch  and  destroy  all  the  infiltrated  tissue 
(see  Chap.  XIX).  The  eye  may  then  remain  closed  for 
several  hours,  unless  conjunctival  discharge  needs  to  be 
removed.  The  slough  left  by  the  cautery  will  in  many 
cases  prevent  the  very  early  recognition  of  extension  of 
the  disease.  But  if  the  application  has  been  sufficiently 
thorough,  subsequent  extension  will  generally  not  occur. 
The  application  of  the  cautery  is  not  in  itself  very  pain- 
ful, if  care  is  taken  not  to  hold  the  heated  metal  close  to 
the  eye,  but  to  touch  the  affected  area  and  then  withdraw 
it ;  and  its  application  is  usually  followed  by  consider- 
able relief  from  pain  due  to  the  ulcer. 

The  removal  of  softened  tissue  by  a  forcible  jet  of 
water  or  some  antiseptic  solution,  called  hydraulic  cu- 
retting, has  been  highly  recommended. 


284  SUPPURATING    ULCER. 

Where  other  means  fail  to  arrest  the  progress  of  the 
ulcer,  a  powerful  influence  in  that  direction  is  brought 
into  play  by  paracentesis  of  the  anterior  chamber.  This, 
by  relaxing  the  tissue  of  the  cornea,  causes  a  considerable 
increase  in  the  stream  of  lymph  passing  into  that  mem- 
brane from  its  nutrient  vessels,  and  allows  the  free  escape 
of  this  fluid  externally,  tending  strongly  to  increase  the 
resisting  power  of  the  corneal  tissue  against  the  attack 
of  pyogenic  organisms.  The  anterior  chamber  may  be 
opened  by  a  broad  needle  or  the  point  of  a  cataract-knife, 
inserted  near  its  lower  margin,  and  then  twisted  in  the 
wound,  sufficiently  to  allow  the  contents  to  drain  away. 
Or  it  may  be  opened  by  what  is  called  the  Saemisch 
incision,  which  must  extend  through  the  cornea  across 
the  ulcer  from  the  sound  tissue  on  one  side  to  the  sound 
tissue  on  the  other  side. 

Opening  the  anterior  chamber  may  also  be  indicated 
to  relieve  the  tension  of  the  cornea  when  the  floor  of  a 
deep  ulcer  seems  to  be  on  the  point  of  bursting.  The 
operative  incision  is  likely  to  heal  without  adhesions  of 
the  iris,  which  would  almost  certainly  occur  should  the 
ulcer  be  allowed  to  perforate.  It  may  be  necessary  to 
reopen  the  incision  on  successive  days  with  a  probe  to 
secure  the  full  benefit  of  this  measure.  After  opening 
the  anterior  chamber,  as  after  perforation  by  the  corneal 
ulcer,  the  extension  of  the  disease  is  generally  checked 
and  recovery  begins. 

As  a  local  application  Chandler  and  Risley  have 
recently  recommended  a  10  per  cent,  ointment  of  cassa- 
reep,  both  to  relieve  pain  and  favorably  influence  the 
course  of  the  disease.  H.  Derby  has  claimed  the  same 
benefits  from  the  use  of  holocain.  A  one  per  cent,  solu- 
tion of  formaldehyd  is  sometimes  beneficial  ;  but  it  causes 
pain  which  cocain  will  not  prevent.  Atropin,  and  some- 
times eserin,  are  of  value  in  relieving  pain  and  improv- 
ing the  circulation. 

In  the  way  of  general  treatment,  rest  in  bed  is  often 
of  great  importance.  Abundance  of  nutritious  food  is 
usually  indicated,  and  in  a  few  cases  alcoholic  stimulants 


DISEASES  OF  THE  CORNEA.  285 

prove  of  value.  These  must,  however,  be  used  with 
great  caution  and  their  effect  watched,  for  alcohol  les- 
sens the  resisting  power  of  the  corneal  tissue  to  the 
action  of  pyogenic  bacteria.  A  remedy  which  seems  to 
increase  the  corneal  resistance  is  tincture  of  the  chlorid 
of  iron,  given  in  rather  large  doses.  Quinin  is  also 
valuable  in  tonic  doses,  one  or  two  grains  three  times  a 
day.  Severe  pain  may  be  relieved  by  small  doses  of 
morphin  or  acetanilid.  It  is  also  relieved  by  hot  appli- 
cations. The  relief  of  pain  is  important  when  it  would 
otherwise  prevent  sleep. 

When  the  extension  of  the  ulcer  has  been  checked 
and  healing  commenced,  the  local  treatment  should  con- 
sist in  atropin,  and  cleanliness  and  rest  of  the  parts,  with 
the  continuance  of  such  treatment  of  the  conjunctiva  as 
may  be  necessary. 

When  perforation  has  occurred  with  prolapse  of  the 
iris,  if  the  ulcer  be  small  and  the  cornea  in  favorable 
condition,  it  may  be  well  to  excise  promptly  the  pro- 
truding iris,  usually  under  general  anesthesia.  The 
prolapse  may  first  be  seized  with  the  forceps,  and 
somewhat  dragged,  first  in  one  direction  and  then  in 
another,  until  it  is  probable  that  the  adhesions  between 
the  cornea  and  the  iris  are  broken  up.  Then  while  the 
iris  is  still  on  the  stretch  the  prolapse  is  to  be  cut  away, 
as  close  to  the  margin  of  the  ulcer  as  possible,  either  with 
the  scissors  or  by  transfixing  it  with  a  cataract-knife  and 
shaving  it  off  close  to  the  cornea.  If  the  operation  has 
been  successful,  the  cut  edges  of  the  iris  will  be  at  once 
retracted  into  the  anterior  chamber  and  away  from  the 
margin  of  the  corneal  perforation.  If  the  neighboring 
cornea  be  much  infiltrated,  or  if  the  prolapse  be  very 
large,  or  of  more  than  one  day's  standing,  it  is  better  to 
leave  it  alone.  If  later  the  cicatrix  shows  a  decided 
tendency  to  excessive  bulging,  healing  may  be  hast- 
ened  and  made  more  satisfactory  by  excision  of  the 
prolapse  (as  described  in  Chap.  XIX)  at  a  later  pe- 
riod. The  treatment  of  the  results  of  corneal  ulcera- 
tions  will  be  considered  under  opacities  of  the  cornea. 


286  CORNEAL    ULCERS. 

Special  Forms  of  Corneal  Ulcer. — In  old  people 
with  impaired  nutrition,  a  form  of  simple  ulcer,  usually 
situated  near  the  margin  of  the  cornea,  associated  with 
conjunctivitis,  and  often  chronic  or  subacute,  causes  great 
pain  without  marked  hyperemia  of  the  eye  or  other  evi- 
dences of  inflammation.  It  shows  little  tendency  to 
extend,  and  little  tendency  to  heal  spontaneously ;  but 
under  the  proper  treatment,  the  instillation  of  a  weak 
solution  of  eserin  and  bathing  the  eye  twice  daily,  or 
oftener,  with  very  hot  water,  and  in  some  cases  with  the 
use  of  a  protective  dressing,  relief  from  pain,  and  healing 
are  promptly  secured. 

Malarial  ulcer  is  common  in  patients  who  have  suf- 
fered from  malarial  disease.  It  is  marked  by  slight 
tendency  to  extension,  much  pain,  and  complete  resist- 
ance to  local  treatment  unless  accompanied  by  the  internal 
use  of  quinin  with  or  without  iron  and  arsenic.  The  ulcer 
is  branching  in  form  ;  and  the  part  of  the  cornea  on  which 
it  is  situated  is  often  quite  insensitive  to  touch.  The  in- 
filtration is  moderate,  and  gray  in  color ;  and  the  pericor- 
neal  redness  commonly  severe. 

Herpetic  ulcer,  described  by  Homer,  occurs  with 
herpes  of  the  lids  and  other  parts  of  the  face,  in  connec- 
tion with  febrile  diseases,  especially  of  the  air-passages, 
as  pharynigitis,  bronchitis,  pneumonia,  etc.  It  begins  with 
small  vesicles  on  the  cornea,  severe  pain,  photophobia  and 
lacrimation.  The  vesicles  are  very  small,  but  may  run 
together  and  form  linear  ulcers  of  considerable  size. 
Healing  depends  on  the  general  nutrition  of  the  patient, 
but  is  usually  prompt.  The  treatment  is  that  for  simple 
corneal  ulcer. 

Dendritic  or  mycotic  ulcer  is  named  from  its  branch- 
ing form,  or  from  its  supposed  dependence  upon  a  special 
micro-organism.  It  is  attended  with  marked  photopho- 
bia, lacrimation,  and  the  hyperemia  of  keratitis.  It 
should  be  treated  by  thorough  scraping,  or  by  touching 
each  part  of  it  lightly  with  the  galvano-cauterv. 

Bullous  keratitis  occurs  when  the  nutrition  of  the  eye 
has  been  damaged  by  previous  disease,  especially  in  con- 


DISEASES  OF  THE  CORNEA.  287 

nection  with  chronic  iridocyclitis  or  glaucoma.  It  also 
occurs  after  traumatisms  causing  extensive  abrasions. 
Blebs  either  small  or  large  form  on  the  surface  of  the 
cornea,  with  pain,  hyperemia,  and  other  symptoms  of 
infiltration.  The  blebs  rupture  leaving  abrasions  or 
deeper  ulcers.  They  tend  to  recur  again  and  again.  The 
treatment  consists  in  atropin  and  hot  applications  locally, 
with  avoidance  of  irritants,  and  a  general  tonic  treatment 
including  quinin  and  iron.  And  in  case  of  traumatic 
origin,  careful  protection  of  the  eye  during  healing.  It 
may  be  necessary  to  enucleate  the  eye  if  blind,  on  account 
of  the  repetition  of  the  attacks. 

Filamentous  keratitis  designates  a  group  of  cases  in 
which  from  a  corneal  ulcer  or  wound-surface  minute 
threads  of  tissue  or  fibrin  are  found  hanging. 

Keratomalacia  is  an  extensive  softening  and  sloughing 
of  the  cornea,  occurring  in  patients  very  poorly  nourished, 
as  after  acute  or  chronic  wasting  disease,  and  especially  in 
infants.  The  treatment  must  be  addressed  to  the  general 
condition,  and  the  eye  guarded  from  irritants. 

Neuropathic  or  neuroparalytiq  keratitis  occurs  after 
disease  of  the  ophthalmic  branch  of  the  fifth  nerve, 
or  its  nuclei.  The  affection  seems  to  be  partly  trophic 
and  partly  traumatic  in  character.  Ulceration  often 
occurs,  but  is  not  extensive  if  the  ulcer  be  guarded  from 
infection.  Some  opacity  of  the  cornea  usually  accom- 
panies it.  This  form  of  ulcer  is  to  be  recognized  particu- 
larly by  testing  the  sensibility  of  the  cornea,  or  finding 
other  evidence  of  disease  of  the  nerve.  It  is  to  be  treated 
by  closure  of  the  eye  under  a  protective  bandage,  the  in- 
stillation of  atropin,  or  a  weak  solution  of  eserin,  cleanli- 
ness, and  careful  avoidance  of  irritants.  Treatment  must 
usually  be  continued  for  several  weeks  or  longer,  until 
the  resisting  power  of  the  cornea  becomes  re-established. 
After  destruction  of  the  Gasserian  ganglion,  this  disease 
may  be  prevented  by  keeping  the  eye  closed  and  carefully 
protected  for  several  weeks. 

Herpes  zoster,  occurring  in  the  distribution  of  the 
ophthalmic  branch  of  the  fifth  nerve,  and  particularly  if 


288  NEUROPATHIC  KERATITIS. 

vesicles  occur  on  the  side  of  the  nose,  is  liable  to  be 
accompanied  or  followed  by  the  involvement  of  the  cor- 
nea. In  some  cases  a  vesicle  forms  on  the  cornea,  leading 
to  ulceration  and  subsequent  opacity.  In  other  cases  the 
cornea!  changes  resemble  those  of  neuropathic  keratitis. 
The  deeper  structures  of  the  eye  may  be  involved  and 
the  sight  entirely  lost.  In  most  cases  sight  is  perma- 
nently damaged  by  resulting  opacity.  The  neuralgic 
pain  which  attends  the  disease  may  last  long  after  the 
local  disease  has  run  its  course. 

Phlyctenular  Keratitis  (Scrofulous  Ophthalmia, 
Strumous  Ophthalmia,  Lymphatic  Keratitis,  Fascicular 
Keratitis,  Vascular  Keratitis). — This  disease  is  essentially 
the  same  as  phlyctenular  conjunctivitis  (see  p.  261),  phlyc- 
tenules  occurring  on  the  cornea  instead  of  at  the  limbus,  or 
upon  other  portions  of  the  conjunctiva.  The  conjunctiva  is 
more  or  less  involved  in  all  cases,  but  the  disease  only 
becomes  obstinate,  severely  painful,  and  dangerous  to 
sight,  when  the  cornea  is  affected.  The  causes  are  those 
of  phlyctenular  conjunctivitis. 

Symptoms  and  CQurse. — The  first  perceptible  lesion 
of  the  cornea  is  an  elevation  of  the  epithelium  at  some 
point  by  an  accumulation  of  a  serous  fluid  beneath  it. 
This  is  the  corneal  phlyctenule.  Michell  has  recently 
found  that  it  is  essentially  a  lesion  of  reaction  against 
micro-organisms,  especially  the  staphylococcus.  The  epi- 
thelium covering  it  quickly  gives  way,  the  fluid  escapes, 
and  a  small  approximately  circular  ulcer  is  left.  This 
occurrence  is  attended  with  pain,  photophobia  and  exces- 
sive lacrimation  ;  and  there  is  hyperemia  of  the  ocular 
conjunctiva  and  of  some  portions,  or  all,  of  the  pericor- 
neal  vessels.  The  photophobia  is  generally  even  more 
marked  than  with  phlyctenular  conjunctivitis.  Often 
two  or  three  or  more  phlyctenules  occur  together,  or  they 
may  follow  each  other  in  quick  succession.  Usually  the 
ulcer  formed  heals  rapidly,  leaving  a  slight  nebula  and 
some  irregularity  of  the  corneal  surface.  But  in  more 
severe  cases,  or  after  repeated  attacks,  the  healing  is  slow, 
superficial  vessels  extend  from  the  limbus  to  the  seat  of 


DISEASES  OF  THE  CORNEA.  289 

the  ulcer,  and  continuing  from  ulcer  to  ulcer  may  form 
a  leash  stretching  to  the  center  of  the  cornea,  or  beyond 
it.  The  disease  shows  a  strong  tendency  to  relapse,  and 
with  successive  attacks,  the  restoration  of  the  eye  to  nor- 
mal during  the  intervals  becomes  less  complete ;  until  it 
remains  continuously  hyperemic,  with  a  clouded  and  vas- 
cular cornea. 

Treatment. — The  general  lines  of  treatment  indicated 
for  phlyctenular  conjunctivitis,  must  be  followed  with 
more  care  and  constancy  when  the  cornea  becomes  in- 
volved ;  and  in  addition  special  measures  must  be  adopted 
for  the  keratitis.  The  irritability  of  the  eyes,  and  dread 
of  exposure  to  the  light  and  air,  cause  the  child  to  bury 
its  eyes  in  a  handkerchief  or  a  pillow,  to  avoid  all  ex- 
posure of  them.  This  is  particularly  unfortunate,  since  it 
tends  strongly  to  aggravate  and  continue  the  disease. 
Indeed,  if  in  any  case  free  exposure  of  the  eyes  to  light 
and  air  can  be  maintained,  the  cure  of  the  eyes,  except  as 
to  removal  of  opacities  and  irregular  astigmatism,  is  not 
usually  difficult.  The  excessive  irritability  is  best  met 
by  instillation  of  a  mydriatic,  preferably  atropin.  A 
powerful  aid  in  this  is  the  regular  application  of  the 
solution  of  tannin  in  glycerin  to  the  inner  surface  of  the 
lids,  once  every  two  or  three  days,  and  the  diffusion  of 
ointment  of  the  yellow  oxid  of  mercury,  in  the  conjunc- 
tival  sac  every  night.  In  addition,  dark  glasses  should 
be  worn  to  protect  the  eyes  from  the  light,  and  to  prevent 
the  constant  application  of  a  handkerchief  to  them,  while 
permitting  the  air  to  circulate  about  them. 

The  small  fissures  which  form  in  the  skin  of  the  lids 
near  the  outer  canthus,  should  be  touched  from  time  to 
time  with  a  solution  of  silver  nitrate,  and  the  skin  care- 
fully dried  and  protected  with  some  petroleum  prepara- 
tion. Where  photophobia  is  very  great  the  sudden  plung- 
ing of  the  face  in  ice-cold  water  has  been  practiced  with 
advantage  ;  but  this  is  rarely  necessary. 

During  the  stage  of  uleeration,  the  treatment  of  simple 
ulcer  of  the  cornea  must  be  followed,  and  care  taken  to 
guard  against  infection.  If  the  ulcer  becomes  chronic 

19 


290  PHLYCTENULAR  KERATITIS. 

and  vessels  extend  out  to  it  from  the  corneal  margin,  it 
should  be  scraped  or  lightly  touched  with  the  actual 
cautery.  For  the  treatment  of  resulting  opacities,  see 
Opacities  of  the  Cornea. 

Prognosis. — Phlyctenular  keratitis  rarely  causes  abso- 
lute blindness ;  but  when  neglected,  it  is  responsible  for 
many  cases  of  life-long  impairment  of  vision.  Promptly 
treated,  such  impairment  can  almost  always  be  prevented. 

Abscess  of  the  Cornea,  Hypopyon  and  Onyx.— 
When  the  process  of  suppuration  at  first  affects  a  limited 
portion  of  the  deeper  tissue  of  the  cornea,  abscess  results. 

It  may  follow  traumatism,  or  be  secondary  to  suppura- 
tion in  other  parts  of  the  eye.  Its  symptoms  are,  in  the 
main,  those  of  suppurating  ulcer  of  the  cornea,  which  it 
tends  to  become  by  the  breaking  down  of  the  more  super- 
ficial layers  of  the  cornea.  It  is  usually  attended  with 
severe  pericorneal  hyperemia  and  great  pain.  In  some 
cases  the  conjunctiva  becomes  chemotic  and  the  lids  ede- 
matous.  The  symptoms  increase  in  severity  with  the 
extension  of  the  abscess  until  it  opens,  usually  upon  the 
corneal  surface ;  after  which  it  runs  the  course  of  a  sup- 
purating ulcer.  It  must  be  distinguished  from  a  plastic 
deposit  or  a  cicatrix  in  the  cornea  chiefly  by  its  color 
and  the  history  of  the  case. 

Hypopyon  is  the  accumulation  of  pus  in  the  anterior 
chamber.  It  may  depend  upon  abscess  or  suppurating 
ulcer  of  the  cornea;  or  upon  suppurative  disease  of 


FIG.  92.— Corneal  ulcer  on  the  upper  temporal  quadrant,  with  hypopyon  occu- 
pying the  lower  one-third  of  the  anterior  chamber. 

the  iris  or  deeper  portions  of  the  eye.  It  is  illus- 
trated in  Fig.  92.  A  considerable  amount  of  pus 
may  pass  through  the  anterior  chamber  without  any 
visible  accumulation.  Only  when  the  amount  poured  into 


DISEASES  OF  THE  CORNEA.  291 

the  aqueous  humor  is  too  great  to  escape  promptly,  or 
when  the  consistence  of  the  material  is  such  as  to  prevent 
its  escape,  does  hyopyon  develop.  Because  some  pus  is 
always  passing  from  the  chamber,  and  the  hypopyon 
represents  only  a  certain  residue  or  excess,  it  may  vary 
greatly  in  amount,  being  at  one  time  barely  perceptible, 
and  a  few  hours  later  filling  a  large  portion  of  the  cham- 
ber. It  appears  as  a  yellowish  mass  behind  the  cornea, 
with  a  curved  lower  border  corresponding  to  that  of  the 
anterior  chamber  and  a  horizontal  upper  margin.  Often 
it  is  promptly  displaced  and  its  upper  margin  changed  by 
a  change  in  the  position  of  the  eye.  But  if  it  contains  a 
considerable  proportion  of  plastic  material  its  form  may 
alter  quite  slowly. 

Onyx  is  an  accumulation  of  pus  in  the  cornea  between 
the  layers  of  the  true  corneal  tissue.  It  occurs  at  the 
lower  portion  of  the  cornea,  by  gravitation  of  pus  from 
a  suppurating  ulcer  or  abscess.  It  is  bounded  above  by 
an  approximately  horizontal  line,  and  is  less  likely  than 
hypopyon  to  change  shape  or  position  with  movement  of 
the  eyes. 

Treatment. — Like  other  purulent  accumulations,  the 
above  should  be  treated  by  free  evacuation  and  drainage. 
When  hypopyon  is  slight,  if  there  be  no  other  indications 
for  opening  the  anterior  chamber,  it  may  be  left  undis- 
turbed. With  onyx,  if  at  all  considerable  in  amount,  it  is 
better  to  incise  the  cornea  deeply  enough  to  allow  the  escape 
of  the  accumulation.  The  corneal  tissue  may  not  at  first 
be  appreciably  involved ;  but  to  allow  it  to  soak  in  the 
purulent  accumulation,  might  convert  it  into  an  ab- 
scess. Corneal  abscess  should  always  be  promptly  and 
freely  opened.  It  never  undergoes  complete  resolution  ; 
and  usually  it  continues  to  extend  until  it  secures  a  free 
exit.  Usually  either  a  crucial  incision  should  be  made, 
or  the  tissue  of  the  cornea  superficial  to  the  abscess  en- 
tirely cut  away,  and  the  abscess-cavity  thoroughly  scraped. 
Even  if  it  is  subsequently  to  be  cauterized,  it  may  be  better 
to  first  freely  open  it.  After  it  has  been  opened,  it  should 
be  treated  as  any  other  suppurating  ulcer. 


292  CORNS AL  INFLAMMATIONS. 


NON-ULCERATIVE  KERATITIS. 

Interstitial  Keratitis  (Parenchymatous,  Syphilitic, 
Strumcrus,  or  Diffuse  Keratitis}. — In  many  cases  inflamma- 
tion of  the  cornea  shows  no  tendency  to  cause  loss  of 
substance,  or  suppuration  ;  but  goes  "on  to  the  deposit  of 
new  material  causing  opacity,  with  often  the  extension  of 
blood-vessels  into  the  cornea.  All  such  cases  properly 
belong  under  the  head  of  Interstitial  Keratitis.  No 
sharp  line  of  distinction  separates  these  from  other  forms 
of  keratitis.  In  superficial  vascular  keratitis,  the  vessels 
and  the  exudation  may  often  be  seen  to  invade  the  true 
corneal  tissue.  The  invasion  is  even  more  common  and 
more  marked  in  pannus.  And  corneal  ulcerations  occa- 
sionally occur  in  the  course  of  typical  interstitial  keratitis. 

Causes. — Under  interstitial  keratitis  are  included  cases 
due  to  many  causes.  Keratitis  attending  herpes  zoster, 
or  fifth-nerve  paralysis  may  be  largely  of  this  character. 
Arlt  named  as  its  most  important  variety  lymphatic  or 
scrofulous  keratitis.  But  Hutchinson's  description  of 
interstitial  keratitis  due  to  hereditary  syphilis,  is  so 
definite  and  fits  so  many  cases,  that  it  is  best  taken  as  the 
type  of  the  disease,  with  which  other  varieties  may  be 
compared.  Even  when  clearly  associated  with  hereditary 
syphilis,  the  attack  may  be  excited  by  acute  illness, 
rheumatism,  eye-strain,  exposure  to  local  irritants,  or 
other  unhealthy  influences  ;  and  relapses  and  recurrences 
are  commonly  so  caused.  Interstitial  keratitis  may  arise 
late  in  the  course  of  acquired  syphilis. 

Symptoms  and  Course. — The  disease  begins  with 
irritability  of  the  eyes,  photophobia,  pericorneal  redness, 
and  interference  with  vision  ;  which,  at  first  very  slight, 
increase  from  day  to  day  until  they  become  intense.  As 
the  symptoms  increase  in  severity,  from  some  part  of  the 
corneal  margin,  most  frequently  above  or  below,  a  broad 
mass  of  fine  looped  vessels  begin  to  encroach  on  the 
cornea.  These  are  surrounded  by  opacity,  and  give  the 
affected  region  a  peculiar  yellowish-red  or  salmon  color. 
Examination  with  a  magnifier  demonstrates  that  the 


DISEASES  OF  THE  CORNEA.  293 

opacity  and  vessels  are  in  the  depth  of  the  cornea.  At 
the  same  time,  the  changes  beneath  it  render  the  corneal 
surface  quite  irregular. 

The  opacity  of  the  cornea  may  increase  until  the  iris 
and  pupil  are  quite  hidden,  and  the  patient  practically 
blind.  Sometimes  before  this,  and  often  after  the  cornea 
has  cleared  up  again,  the  iris  may  be  seen  to  be  bound 
down  by  posterior  synechise  of  greater  or  less  extent. 
In  a  few  cases,  deposits  in  the  anterior  chamber  also  cause 
extensive  anterior  synechise,  without  there  having  been 
any  perforation  of  the  cornea.  Sometimes  one  eye  is 
affected  before  the  other,  or  more  severely  affected  than 
the  other;  but  usually  both  are  involved.  The  cornea 
may  resemble  ground  glass,  or  the  deposits  in  certain 
parts  may  be  completely  opaque.  Sometimes  they  are  so 
dense  and  yellow  as  to  look  like  corneal  abscess ;  and 
if  attended  by  decided  swelling,  may  properly  be  regarded 
as  gumma  of  the  cornea. 

After  a  time,  which  varies  from  a  few  weeks  to  many 
months,  the  corneal  opacity  begins  to  grow  less  dense. 
This  is  first  noticed  near  the  margin  of  the  cornea,  the 
center  remaining  clouded  longest.  But  at  length  the  cen- 
tral cloud  gets  thinner,  and  the  corneal  vessels  diminish 
in  size  and  grow  less  numerous.  Some  of  the  vessels, 
however,  often  remain  and  may  be  discovered  with  a 
magnifier  years  afterward,  or  throughout  life.  Usually 
the  cornea  becomes  comparatively  clear  again,  but  almost 
always  shows  some  haziness  by  oblique  illumination, 
and  causes  marked  irregular  astigmatism  with  correspond- 
ing permanent  impairment  of  vision.  In  many  cases, 
even  when  carefully  treated  throughout,  the  iris  is  left 
bound  down  by  synechise.  Often,  too,  the  ophthal- 
moscope shows  that  the  inflammation  has  involved  other 
parts  of  the  uveal  tract ;  and  patches  of  choriodal 
atrophy,  and  pigment  changes  remain  as  permanent 
records  of  the  attack.  Interstitial  keratitis  occurs  chiefly 
between  the  ages  of  five  years  and  twenty.  Its  duration 
is  from  a  few  weeks  to  two  or  three  years ;  and  slow 
clearing  of  the  cornea  may  continue  even  longer. 


294  INTERSTITIAL  KERATITIS. 

Varieties. — When  not  due  to  inherited  syphilis,  the 
disease  is  apt  to  run  a  less  uniform  course,  and  periods 
of  improvement  may  alternate  with  exacerbations.  The 
cornea  is  often  less  vascular,  the  vessels  do  not  run  in 
such  characteristic  loops,  and  the  opacity  is  less  likely  to 
be  evenly  distributed.  When  due  to  scrofula,  there  is 
more  apt  to  be  ulceration. 

In  a  few  cases,  a  cloud  of  opacity  is  limited  to  a  cer- 
tain part  of  the  cornea,  usually  the  center,  and  but  few 
if  any  corneal  vessels  develop  (circumscribed  infiltration  of 
the  cornea). 

Occasionally,  in  connection  with  a  focus  of  scleritis 
situated  near  the  corneal  margin,  a  somewhat  triangular 
opacity  will  extend  into  the  cornea,  which  to  some  extent 
becomes  permanent,  and  appears  as  an  extension  of  the 
sclera.  This  process  may  be  repeated  at  various  parts  of 
the  corneal  margin.  It  is  called  sclwosing  keratitis.  In  rare 
cases  in  old  people,  there  sometimes  occurs  a  yellowish 
exudation  at  the  margin  of  the  cornea,  with  symptoms  of 
inflammation  which  later  subside.  The  vessels  of  the 
limbus  extend  in  over  it,  the  opacity  becomes  gray,  and 
closely  resembles  an  arcus  senilis,  except  that  no  clear 
tissue  separates  it  from  the  corneal  margin.  This  is  called 
keratitis  marginalis. 

Diagnosis. — Interstitial  keratitis  is  recognized  by  the 
general  distribution  of  the  opacity  in  the  cornea,  its 
depth,  and  the  form  and  situation  of  the  vessels.  The 
vessels  are  arranged  in  fine  approximately  parallel  loops, 
which  start  from  the  deeper  portions  of  the  corneal  mar- 
gin. This  is  illustrated  in  Fig.  93,  in  which  A  represents 
the  vessels  in  interstitial  keratitis,  B  those  of  phlyctenu- 
lar  keratitis,  and  C  those  of  pannus.  In  these  latter 
forms  of  vascular  keratitis,  the  vessels  start  from  con- 
junctival  vessels  and  increase  in  number  and  diminish  in 
size  by  branching  off  from  main  trunks. 

The  pericorneal  redness  is  usually  unmistakable  at 
the  height  of  the  attack,  although'  there  may  be,  in 
addition,  some  conjunctival  hyperemia.  At  an  early 
stage  the  diagnosis  will  be  greatly  aided  by  other  evi- 


DISEASES  OF  THE  CORNEA.  295 

dences  of  inherited  syphilis,  especially  the  sunken 
bridge  of  the  nose,  scars  about  the  angles  of  the 
mouth,  and  the  Hutchinson  teeth.  The  characteristic 
deformities  of  the  teeth  consist  in  the  notching  of  the 
central  incisors,  and  the  peg  shape  and  deficient  develop- 


FIG.  93. —Vascular  keratitis.    Distribution  of  corneal  vessels  in  the  various 
forms.    A,  Interstitial ;  B,  Phlyctenular  or  fascicular;  C,  Pannus 

ment   of    the   lateral    incisors.      These    are    shown    in 
Fig.  94. 

These  deformities  are  only  exhibited  by  the  permanent 
teeth.  The  milk  teeth  are  generally  poor,  decaying  often 
down  to  the  gums  before  they  are  replaced.  Any  marked 
deformity  of  the  permanent  incisors,  especially  if  they 
are  small  so  that  they  do  not  fill  the  jaw,  but  stand 
separately  with  gum  showing  between,  may  be  due  to 
inherited  syphilis.  But  as  Harrison  Allen  pointed  out, 
considerable  disturbances  in  the  development  of  the 


FIG.  94.— Hutchinson  teeth. 

teeth  are  also  caused  by  the  exanthemata  of  childhood, 
occurring  when  the  crown  of  the  tooth  is  developing. 
Some  deformity  of  the  teeth  is  present  in  half  the  cases 
of  interstitial  keratitis.  The  history  of  still-births,  or 
repeated  miscarriages  before  the  birth  of  the  patient,  also 
points  strongly  to  inherited  syphilis. 


296  INTERSTITIAL  KERATITIS. 

After  the  keratitis  has  run  its  course,  the  existence  of 
synechiae,  or  patches  of  choroidal  atrophy  and  pigment- 
changes,  indicate  the  nature  of  the  disease  that  has  left 
the  cornea  defective.  The  same  evidences  may  raise  a 
strong  probability  of  intra-uterine  interstitial  keratitis, 
causing  congenital  opacity  of  the  cornea. 

Impaired  hearing  due  to  lesions  of  the  internal  ear 
often  coming  on,  or  growing  worse  at  the  time  of  the 
keratitis,  also  indicates  syphilis. 

Treatment. — The  local  treatment  should  include  the 
regular  instillation  of  a  solution  of  atropin,  so  long  as 
there  continues  any  pericorneal  redness ;  and  afterward 
until  the  eyes  cease  to  be  unduly  irritable.  The  strength 
of  the  solution  and  the  frequency  of  the  instillations 
should  be  sufficient  to  keep  the  pupil  well  dilated ;  or  if 
this  cannot  be  accomplished,  as  much  atropin  must  be 
instilled  as  can  be  used  without  causing  serious  general 
symptoms  of  mydriatic  intoxication.  Atropin  is  to  be 
preferred  to  other  strong  mydriatics  because  its  action  is 
more  persistent,  and  it  is  less  likely  to  cause  general 
symptoms. 

The  action  of  the  atropin  may  be  aided,  and  pain  dimin- 
ished by  bathing  the  eyes,  for  three  to  five  minutes  before 
each  instillation  of  the  drug,  with  very  hot  water.  If 
the  hyperemia  is  very  great,  a  decided  beneficial  influence 
is  exerted  by  abstracting  an  ounce  or  more  of  blood  from 
the  temple  with  the  artificial  leech.  This  should  be  done 
in  the  evening  when  it  will  have  most  influence  in  pro- 
curing sleep.  Dark  glasses  should  be  worn  to  lessen  the 
photophobia.  Subconjunctival  injections  of  mercuric 
chlorid  have  been  tried,  but  are  of  doubtful  value.  All 
other  local  treatment  should  be  avoided  during  the  earlier 
stages.  Astringent  and  irritant  applications  are  harmful. 
When  the  hyperemia  is  almost  gone,  the  ointment  of 
yellow  ox  id  of  mercury  may  be  used  to  hasten  the  clear- 
ing up  of  the  opacity ;  and  other  measures  for  the  same 
purpose  will  be  indicated  later  (see  p.  304). 

The  constitutional  treatment  is  very  important.  This 
should  include  a  general  tonic  regimen,  and  for  a  case 


DISEASES  OF  THE  CORNEA.  297 

caused  by  syphilis  a  long-continued  course  of  mercury  in 
moderate  doses.  The  child  should  have  plenty  of  sleep ; 
a  carefully  regulated  nutritious  diet,  avoiding  tea,  coffee, 
and  sweets ;  regular  cold  bathing ;  and  out-of-door  life, 
away  from  dust  and  smoke,  if  possible.  Syrup  of  iodid 
of  iron,  syrup  of  hydriodic  acid,  or  tincture  of  the  chlorid 
of  iron  may  be  given.  Cod-liver  oil  is  sometimes  very 
valuable.  The  mercurial  course  may  begin  with  calomel, 
until  the  bowels  are  decidedly  acted  upon,  and  then  be 
changed  to  inunctions  with  a  drachm  of  mercurial 
ointment  once  daily.  If  the  mouth  becomes  at  all 
affected,  the  mercury  should  be  suspended,  and  potas- 
sium iodid  in  moderate  doses  (5  grains)  given  until 
the  mouth  is  well.  Then  the  mercury  may  be  given 
in  smaller  dose.  After  the  inflammation  has  passed  its 
height,  the  mercurial  may  be  given  in  small  doses 
internally  with  potassium  iodid. 

Prognosis. — Interstitial  keratitis  may  last  from  a  few 
weeks  to  five  years.  Very  few  cases  recover  under  two 
months,  and  the  majority  are  fairly  over  it  within  a  year. 
But  no  one  can  tell  at  the  outset  how  long  the  particular 
case  will  continue.  It  is  safe  in  the  beginning  to  predict 
that  the  sight  will  get  worse ;  and  at  the  height  of  the 
disease,  one  can  surely  promise  that  it  will  greatly  im- 
prove in  the  end.  Very  few,  if  any  cases  recover  normal 
vision  ;  but  the  final  opacity  of  the  cornea  may  be  scarcely 
distinguishable.  Recurrences  of  the  disease  are  rare  ;  but 
they  may  occur  years  later,  and  generally  leave  the 
patient  with  poorer  vision  than  he  had  after  the  first 
attack. 

Punctate  keratitis  is  a  term  that  has  been  applied 
to  the  small  points  of  deposit  which  occupy  a  triangular 
space  on  the  posterior  surface  of  the  cornea  in  cyclitis 
and  iridocyclitis.  But  in  typical  cases  it  is  uncertain  if 
the  condition  of  the  cornea  has  any  connection  with  their 
formation,  or  does  more  than  furnish  them  a  resting- 
place.  In  some  cases  of  interstitial  keratitis,  the  opacity, 
especially  at  a  late  stage  of  the  disease,  consists  chiefly 


298  PUNCTATE  KERATITIS. 

of  points  grouped  in  the  lower  portion  of  the  cornea, 
keratitis  punctata  syphilitica,  or  profunda. 

A  form  of  inflammation  closely  allied  to  corneal  herpes, 
but  with  little  tendency  to  the  formation  of  ulcers  has 
been  termed  keratitis  punctata  superficialis.  It  begins 
with  symptoms  of  acute  catarrhal  conjunctivitis.  But 
several  days  later,  minute  gray  dots  are  found  scattered 
irregularly  over  the  corneal  surface,  being  least  numerous 
near  the  margin. 

Stliate  keratitis  occurs  after  injuries  to  the  cornea. 
It  is  characterized  by  lines  of  rather  faint  gray  opacity, 
that  appear  within  the  first  two  days  after  the  injury. 
It  is  most  frequently  seen  after  cataract  extraction, 
when  the  lines  are  found  perpendicular  to  the  direction 
of  the  corneal  incision.  It  is  not  of  serious  significance, 
being  unattended  with  other  evidences  of  corneal  inflam- 
mation, and  ultimately  disappearing  in  all  cases,  often 
within  a  week.  It  probably  depends  on  dilatation  of 
lymph-spaces  from  general  disturbance  of  the  cornea,  as 
in  the  delivery  of  a  full-sized  hard  cataract. 

PanntlS  (trach&matous  keratitis,  superficial  vascular 
keratitis)  is  primarily  a  disease  of  the  conjunctiva  cover- 
ing the  cornea.  But  since  the  deeper  layers  of  the  cor- 
nea become  involved,  and  it  is  attended  with  all  the 
symptoms  of  keratitis,  it  is  well  to  consider  it  here. 

Causes  and  Varieties. — The  vascular  opacity  some- 
times left  by  prolonged  phlyctenular  keratitis  has  been 
called  pannus.  But  the  application  of  the  term  is  now 
usually  restricted  to  the  condition  arising  in  trachoma. 
If  the  layer  of  hazy  vascular  tissue  be  thin  it  is  pannus 
tennis ;  if  it  be  thick  and  fleshy,  pannus  crassus. 

Symptoms  and  Course. — Pannus  does  not  arise  in 
the  course  of  trachoma,  until  that  disease  is  well  estab- 
lished, causing  marked  roughening  of  the  inner  surface 
of  the  lids.  It  occurs  chiefly  in  cases  in  which,  on 
account  of  swelling  of  the  lids,  or  for  other  reasons,  the 
eyes  are  not  kept  fully  open.  It  may  develop  rapidly 
with  intense  hyperemia,  causing  severe  photophobia  and 
practical  blindness,  in  a  few  weeks.  The  patient  may 


DISEASES  OF  THE  CORNEA.  299 

date  the  commencement  of  his  eye  trouble  from  the 
beginning  of  the  pannus,  not  counting  the  trachoma 
which  may  have  existed  a  long  time  previously.  It  con- 
sists in  great  thickening,  vascularity,  and  haziness  of  the 
superficial  layers,  of  those  parts  of  the  cornea  which  are 
most  continuously  in  contact  with  the  lids.  The  part 
always  affected  is  the  upper  part  of  the  cornea,  sometimes 
as  far  down  as  the  center.  In  some  cases  a  small  area  at 
the  lower  margin  is  also  involved.  The  usual  distribu- 
tion of  the  pannus  is  shown  in  Fig.  87.  Sometimes  it  is 
complicated  with  deep  ulceration  of  the  cornea. 

Abrasions  of  the  surface  are  frequent.  In  most  cases 
if  the  lids  are  comparatively  cured,  rendered  smooth  and 
free  from  active  disease,  the  pannus  disappears,  or  is 
reduced  to  a  slight  haziness,  with  a  few  inconspicuous 
vessels.  If,  however,  the  lids  have  been  much  deformed 
by  the  disease,  and  especially  if  they  press  upon  the  cor- 
nea with  permanent  narrowing  of  the  palpebral  fissure, 
the  pannus  may  remain  after  the  trachoma  has  ceased  to 
be  active. 

Diagnosis. — The  portion  of  the  cornea  affected,  and 
the  condition  of  the  lids  will  distinguish  pannus  from 
pterygium.  The  horizontal  boundary  quite  separates  it 
from  other  vascular  opacities  of  the  cornea ;  and  a  close 
inspection  of  the  vessels  shows  their  characteristic  forma- 
tion. This,  with  other  forms  of  corneal  vascularity  is 
illustrated  diagrammatically  in  Fig.  93. 

Treatment. — In  a  large  proportion  of  cases  of  pannus, 
the  only  treatment  required  is  that  of  the  trachoma.  As 
the  lids  improve,  the  pannus  improves  equally,  often 
becoming  unimportant  long  before  the  treatment  of  the 
trachoma  can  be  safely  suspended.  This  is  especially 
the  case  when  the  trachoma  is  efficiently  treated  from  a 
period  shortly  after  the  development  of  the  pannus.  The 
effect  on  the  pannus  of  a  thorough  rolling  of  the  lids  is 
sometimes  very  prompt  and  remarkable.  But  in  chronic 
cases  special  measures  must  sometimes  be  resorted  to. 
Photophobia  and  pain  are  usually  much  lessened  by  in- 
stillations of  atropin,  or  one  of  the  other  mydriatics.  But 


300  PANNUS. 

it  must  be  borne  in  mind  that  in  a  few  persons  these 
drugs  aggravate  any  form  of  conjunctivitis  ;  and  trachoma 
is  no  exception. 

If  there  be  marked  shrinking  of  the  palpebral  aperture, 
and  pressure  of  the  lids  upon  the  globe,  canthoplasty  should 
be  done.  It  increases  the  efficiency  of  applications  for  the 
trachoma,  and  greatly  lessens  the  traumatism  to  which  the 
cornea  is  continuously  subjected. 

Formerly  inoculation  of  the  eye  with  gonorrheal  pus 
was  a  recognized  remedy  for  pannus.  It  was  often  effec- 
tive in  thinning  the  pannus,  and  the  danger  of  corneal 
perforation  was  much  less  than  in  the  normal  eye,  on  ac- 
count of  the  vascularity  of  the  cornea.  But  it  has  of 
late  years  been  replaced  by  the  use  of  jequirity,  which 
produces  much  the  same  effect  with  less  risk.  It  is  ap- 
plied either  as  an  infusion,  lightly  brushed  on  the  inner 
surface  of  the  upper  lid,  or  as  an  impalpable  power  dusted 
on  the  same  part  (see  Chap.  XVIII).  It  produces  a 
sharp  purulent,  or  croupous  conjunctivitis,  which  runs  its 
course  in  a  few  days,  leaving  the  lids  and  pannus  decidedly 
better. 

Where  severe  pannus  remains  after  the  condition  of 
the  lids  seems  no  longer  to  furnish  a  sufficient  cause  for 
it,  the  vascular  surface  may  be  curetted  away,  the  ves- 
sels may  be  closed  as  they  pass  on  the  cornea  by  burning 
a  line  with  the  galvano-cautery,  or  peritomy  may  be  done 
(see  Chap.  XIX). 

Persistent  opacity  that  is  almost  non-vascular  may 
require  other  treatment  given  for  the  removal  of  corueal 
opacities. 

Prognosis. — Severe  pannus  is  never  followed  by  per- 
fect recovery,  but  there  may  be  restoration  of  good  vision. 
The  ultimate  condition  of  the  cornea  will  depend  largely 
on  that  of  the  lids. 

CORNEAL  OPACITIES. 

Causes  and  Varieties. — The  physiological  opacity 
which  may  be  brought  out  as  a  diffused  haziness  in  the 


DISEASES  OF  THE  CORNEA.  301 

normal  cornea,  and  resolved  under  a  strong  magnifier 
into  separate  dots  and  masses,  must  not  be  confused  with 
opacities  due  to  disease.  Arcus  senilis  is  usually  seen  in 
the  aged,  but  sometimes  iu  early  life.  It  is  a  gray  arc 
separated  from  the  upper  and  lower  margins  by  a  narrow 
strip  of  clear  cornea.  It  tends,  with  time,  to  become 
denser,  and  to  extend  in  a  complete  circle  (see  Fig.  95). 
It  is  no  contraindication  to  corneal  operations,  nor  does 
it  indicate  fatty  degeneration  in  other  organs. 

A  faint  haziness  of  the  cornea  left  by  preceding  inflam- 
mation is  a  nebula,  a  spot  of  more  decided  gray  opacity  a 
macula,  and  a  dense  cicatricial  opacity,  usually  white  in 
color,  a  leukoma.  The  density  of  an  opacity  left  by  an 
ulcer  depends  largely  on  its  depth.  Usually  a  perforat- 
ing ulcer  causes  leukoma,  and  if  the  perforation  has  been 
at  all  large,  some  part  of  the  iris  is  apt  to  remain  con- 
nected with  the  scar,  making  it  an  adherent  leukoma. 
Such  an  opacity  will  often  present  a  few  rather  large 
vessels  which  arise  from,  or  inosculate  with,  those  of  the 
iris  (see  Fig.  96). 


FIG.  95.  FIG.  96. 

FIG.  95.— Arcus  senilis. 

FIG.  96. — Adherent  leukoma,  point  of  included  pigment  near  its  center,  large 
vessel  extending  on  it  from  the  conjunctiva,  and  pupil  distorted  by  traction 
on  the  iris. 

Congenital  opacity  of  the  cornea  occurs  in  the  form 
of  minute  scattered  dots,  probably  due  to  intra-uterine 
keratitis.  Another  form  is  that  of  a  dense  leukoma  oc- 
cupying the  center  of  the  cornea,  and  sometimes  extend- 
ing almost  to  the  corneal  margin.  It  is  due  to  arrest  of 
the  clearing  of  the  cornea,  which  is  all  opaque  at  an  early 
stage  of  development.  Sometimes  these  opacities  greatly 
diminish  after  birth.  Another  variety  of  central  opacity 
of  the  cornea,  sometimes  hereditary,  has  been  known  to 
develop  after  birth. 


302  COBNEAL   OPACITIES. 

Band-like  opacity  of  the  cornea  occurs  in  two  forms.  A 
very  few  old  people,  with  eyes  otherwise  apparently  healthy, 
present  a  gray  film  covering  the  pupil,  and  occupying 
most  of  the  corneal  surface  habitually  exposed  when  the 
lids  are  opened,  the  corneal  margin  remaining  clear. 
The  opacity  lies  close  to  the  surface,  but  the  surface  itself 
remains  smooth.  Its  appearance  is  illustrated  in  Fig.  97. 


FIG.  97. — Band-like  opacity  of  the  cornea. 

It  is  attended  by  no  symptoms  of  irritation,  but  greatly 
impairs  the  vision.  Under  cocain,  the  epithelium  and 
underlying  film,  which  consists  partly  of  lime  salts,  may 
be  scraped  away,  and  the  resulting  abrasion  treated  with 
boric  acid  solution  and  duboisin  or  atropin  dissolved  in 
petrolatum.  There  is  usually  no  tendency  for  it  to 
return. 

Another  band-like  opacity  of  the  cornea  is  frequently 
seen  in  patients  of  all  ages ;  aifecting  eyes  that  are  blind 
from  previous  disease,  and  which  are  undergoing  marked 
degenerative  changes.  It  occupies  the  same  exposed 
region.  The  opacity  is  not  a  uniform  film,  but  (lotted, 
and  the  surface  of  the  cornea  has  lost  its  smoothness  and 
luster.  It  is  often  attended  with  symptoms  of  irritation, 
and  may  be  an  indication  for  the  enucleation  or  eviscera- 
tion of  the  eye. 

Opacity  following  the  prolonged  application  of  a 
lead-lotion  to  an  abraded  or  ulcerated  cornea,  is  of  a 
dense  white  color  and  situated  just  below  the  eorneal  sur- 
face. It  is  usually  said  to  be  due  to  a  precipitation  of 
some  insoluble  lead  compound.  Recently,  however,  some 
films  of  the  kind  have  been  examined,  in  which  no  trace 
of  lead  was  found.  Such  opacities  may  be  removed  by 
scraping.  Sometimes  they  are  thrown  off  spontaneously. 


DISEASES  OF  THE  CORNEA.  303 

Gray  opacity  of  the  cornea  occurs  also  from  irido- 
choroiditis,  from  contact  of  exudates  with  the  posterior 
surface  of  the  cornea,  and  in  glaucoma,  and  from  burns 
and  other  injuries. 

Opacity  of  the  cornea  from  staining  with  blood-pig- 
ment occurs  in  some  cases  of  extensive  hemorrhage  into 
the  anterior  chamber.  The  cornea  becomes  of  a  smoky  red- 
dish-brown color,  the  cloud  of  discoloration  being  always 
most  dense  at  the  center.  The  margin  of  the  cornea 
remains  comparatively  clear  throughout,  and  in  the  end 
the  whole  membrane  usually  clears  up. 

Pigmentation  of  the  cornea  occurs  after  chronic  in- 
flammation with  increased  tension ;  points  of  previously 
gray  opacity  becoming  altered  to  black  or  brown  pigment- 
specks  which  may  be  permanent. 

Symptoms. — Corneal  opacity  impairs  vision,  not  only 
by  preventing  properly  focussed  light  from  entering  the 
eye,  but  also,  when  strongly  illuminated,  by  throwing 
into  the  eye  a  large  amount  of  diffused  light,  which 
"  drowns  out "  the  impression  of  such  focussed  light  as 
may  reach  the  retina.  Any  decided  opacity  of  the  cornea 
is  a  personal  disfigurement,  to  escape  which  patients  fre- 
quently seek  the  assistance  of  the  surgeon. 

Treatment. — Recent  opacities  following  corneal  in- 
flammations continue  to  diminish  spontaneously  for 
months  or  even  years.  Such  diminution  is  partly  by 
alteration  of  new  tissue  into  closer  correspondence  with 
the  normal  tissue  of  the  cornea,  and  partly  by  removal 
of  exudates.  Certain  mercurial  preparations,  especially 
the  ointment  of  the  yellow  oxid,  and  calomel  dusted  upon 
the  surface  of  the  cornea,  have  a  reputation  for  hastening 
the  latter  process.  It  should  be  remembered  that  calomel 
should  not  be  dusted  in  the  eyes  when  potassium  iodid  is 
taken  internally ;  for  the  iodid  being  largely  excreted 
through  the  tears,  an  intensely  irritant  compound  is 
formed  which  causes  a  violent  conjunctivitis. 

When  the  process  of  resorption  comes  to  a  standstill, 
it  can  often  be  rendered  active  again  by  various  decided 
irritants.  Thus  massage  with  powdered  boric  acid,  or 


304  TREATMENT  OF  OPACITIES. 

other  substances,  through  the  closed  lid,  or  direct  mas- 
sage of  the  cornea  may  have  the  desired  effect.  Direct 
massage  of  the  cornea  may  be  made  with  a  corneal  spa- 
tula, or  the  back  of  a  lens-spoon,  using  considerable  pres- 
sure over  the  spots  of  opacity,  but  not  enough  to  provoke 
severe  or  prolonged  irritation.  The  massage  should  be 
repeated  at  intervals  of  three  days  to  two  \veeks. 

Galvanic  electricity  may  be  used  upon  some  chronic 
opacities  with  decided  benefit.  The  cathode  applied  to 
the  cornea  should  terminate  in  a  metal  cup  which  accu- 
rately fits  it,  in  which  may  be  placed  a  drop  of  mercury. 
The  broad  anode  of  sponge  is  applied  to  the  cheek. 
From  ^  to  1^  milliamperes  of  current  are  to  be  applied, 
for  from  one  to  three  minutes.  The  application  is  made 
under  cocain  ;  and  there  should  be  little  if  any  subsequent 
irritation.  It  may  be  repeated  every  two  or  three  days. 

In  adherent  leukoma,  the  greatest  diminution  in  the 
opacity  will  be  brought  about  by  dividing  the  adhesions 
of  the  iris  to  the  cornea.  An  operation  accomplishing 
this  often  causes  enlargement  of  the  pupil,  and  the  ad- 
mission of  a  greater  amount  of  diffuse  light,  by  which 
vision  is  made  worse  rather  than  better.  To  diminish 
the  light  admitted  through  the  hazy  part  of  the  cornea, 
tattooing  has  been  advocated  (Wecker).  To  secure  a 
pupil  removed  from  the  corneal  opacity,  optical  iridec- 
tomy  may  be  resorted  to.  If  the  patient  is  practically 
blind  before,  he  may  be  greatly  benefited  by  optical 
iridectomy ;  but  if  he  previously  possessed  moderate 
vision,  the  operation  is  apt  to  be  disappointing.  Trans- 
plantation of  the  cornea  from  one  of  the  lower  animals  is 
only  applicable  to  the  very  rare  cases  of  dense  permanent 
central  opacity,  in  which  there  has  been  no  perforation 
of  the  cornea ;  and  in  these  it  has  been  of  little  practical 
value.  When  the  eye  is  entirely  blind,  tattooing  of  the 
cornea  or  enucleation  or  evisceration  of  the  eye  may  be 
done  for  cosmetic  reasons. 

Prognosis. — Decided  opacity  of  the  cornea,  especially 
if  it  extend  deeply,  rarely  or  never  clears  up  entirely. 
The  greatest  improvement  is  seen  in  early  childhood, 


DISEASES  OF  THE  CORNEA.  305 

especially  after  interstitial  keratitis.  When  dense  opacity 
has  to  a  great  extent  cleared  up  in  early  life,  it  may 
partly  return,  with  the  degenerative  changes  of  old  age. 
Even  eyes  that  have  become  free  from  noticeable  corneal 
opacity,  generally  retain  enough  irregular  astigmatism  to 
greatly  impair  vision. 

PROTRUSIONS  OF  THE  CORNEA. 

Anterior  Staphyloma  (Corneal  Staphyloma). — 
Causes. — After  a  large  perforation  of  the  cornea,  and 
extensive  prolapse  of  the  iris,  the  portion  of  iris  remain- 
ing embedded  in  the  scar-tissue  which  replaces  the  cornea, 
drags  the  other  parts  of  the  iris  in  close  contact  with  the 
corneal  margin,  and  effectually  closes  the  chief  outlet  for 
intra-ocular  fluid  (see  Chap.  XV).  The  scar  also,  being 
relatively  less  resistant  than  the  normal  solera,  often 
gives  way  before  the  intra-ocular  tension  and  bulges. 
Prolapse  of  the  iris  always  bulges  when  it  occupies  a 
perforation ;  but  later  the  deposit  of  new  tissue,  and  its 
cicatricial  contraction,  usually  flattens  it  down.  At  this 
stage  the  intra-ocular  fluid  still  finds  sufficient  avenues  of 
escape.  Later  still,  when  the  same  cicatricial  contraction 
has  drawn  the  whole  iris  into  closer  contact  with  the  cor- 
nea, and  has  consolidated  the  tissue,  rendering  it  com- 
paratively impervious  to  intra-ocular  fluids,  the  pressure 
within  the  eye  rises  to  such  an  extent  as  to  cause  the 
secondary  distention  designated  staphyloma.  Or  the  dis- 
tention  may  remain  throughout,  while  the  scar-tissue 
thickens  up  and  the  prolapse,  without  material  change  of 
shape,  becomes  a  staphyloma.  When  the  whole  cornea 
becomes  involved  in  the  process,  the  case  is  said  to  be 
one  of  total  staphyloma,  when  part  of  the  cornea  remains 
comparatively  unaltered  it  is  partial  staphyloma. 

Symptoms. — Decided  anterior  staphyloma  causes  so 
much  protrusion,  that  its  presence  and  movements  may 
be  recognized  through  the  closed  lids ;  and  if  very  large 
it  renders  complete  closure  of  the  lids  impossible.  The 
most  prominent  portion  of  the  staphyloma  protruding  con- 
20 


30G  ANTERIOR  STAPHYLOMA. 

tinuotisly  between  the  lids  becomes  red  and  irritated,  or 
dry  and  skin-like  in  appearance.  The  staphyloma  is 
always  opaque ;  but  if  very  recent  it  may  be  so  thin 
that  the  dark  pigment-layer  lining  it  shows  through,  giv- 
ing it  a  grayish-purple  color, 
the  resemblance  of  which  to 
that  of  a  ripe  grape  gave  the 
name  to  this  condition.  Usu- 
ally this  color  is  gradually  lost, 
the  most  of  the  scar  becoming 
rather  white,  with  some  few 
vessels  in  it ;  and  perhaps  one 
or  more  masses  of  black  pig- 
ment from  the  incarcerated  iris. 
The  margin  of  the  staphyloma 

(what    wag   the    margjn   of  tne 

cornea)  may  remain  partly 
transparent;  and  through  this  the  iris  is  apt  to  give  a 
blue-gray  color.  The  appearance  of  conical  staphyloma 
is  illustrated  in  Fig.  98. 

The  rubbing  of  the  lids  by  the  protruding  mass  may 
cause  symptoms  of  irritation  ;  or  the  simple  stretching  or 
pinching  of  nerves  in  the  scar-mass  may  cause  pain.  The 
protrusion  may  remain  stationary  for  months  or  years ; 
but  it  is  always  liable  to  give  way  before  the  intra-ocular 
pressure  and  become  more  distended.  The  pressure  is 
especially  effective  at  the  re-entering  angle,  where  the 
staphyloma  joins  the  normal  outline  of  the  eyeball. 
Partial  staphyloma,  therefore,  tends  to  become  total  ;  and 
total  to  increase,  so  that  a  staphyloma  once  covered  by  the 
lids  comes  to  protrude  between  them.  If  allowed  to  go 
on,  the  process  ends  in  rupture  of  the  weakest  part  of  the 
staphyloma,  and  escape  of  a  large  amount  of  aqueous 
humor.  After  this,  the  staphyloma  partly  collapses,  the 
rent  closes,  and  the  distention  again  occurs.  This  may  be 
repeated,  but  ultimately  the  rupture  is  apt  to  set  up  a  gen- 
eral inflammation  of  the  uveal  tract,  which  ends  in  shrink- 
ing of  the  eyeball.  Sometimes  a  corneal  staphyloma 
leads  to  general  distention  of  the  eyeball. 


DISEASES  OF  THE  CORNEA.  307 

The  opacity  of  total  staphyloma  always  causes  blind- 
ness. Even  if  some  part  of  the  cornea  remains  clear  in 
partial  staphyloma,  it  is  usually  so  distorted  as  to  allow 
very  imperfect  vision.  If  the  staphyloma  be  progressive 
all  useful  sight  may  be  lost.  Eyes,  so  blinded,  retain 
good  perception  of  light  often  for  many  years,  especially 
in  children,  where  the  distensibility  of  the  solera  long 
saves  the  retina  from  loss  of  function  through  pressure. 
A  child  with  double  staphyloma  will  often  find  great 
enjoyment  in  holding  its  spread  fingers  between  its  eyes 
and  the  light,  and  moving  them  from  side  to  side  to  get 
the  effect  of  the  alternate  light  and  shadow. 

Diagnosis. — Corneal  staphyloma  will  be  easily  distin- 
guished from  the  other  kinds  of  opacity  of  the  cornea  by 
the  marked  departure  from  the  normal  outline  of  the  eye- 
ball. From  new  growths  affecting  the  front  of  the  eyeball 
it  may  be  known  by  the  comparative  absence  of  vascular- 
ity,  the  whiteness  of  the  center,  in  contrast  with  the  blue- 
gray  margin,  and  the  history  of  antecedent  inflammation 
and  long  continuance  without  much  change  of  appearance. 
Then,  too,  in  staphyloma  the  solera  is  evidently  contin- 
uous with  the  tumor;  not  overlaid  or  burst  through  as 
in  the  case  of  a  new  growth. 

The  diagnosis  between  total  and  partial  staphyloma 
must  be  made  on  account  of  the  difference  in  prognosis 
and  treatment.  The  chief  difficulty  lies  in  the  deceptive 
appearance  of  clear  cornea  with  the  iris  behind  it,  presented 
by  the  margin  of  a  total  staphyloma.  Unless  an  appre- 
ciable depth  of  anterior  chamber  can  be  made  out  between 
the  periphery  of  the  cornea  and  the  iris,  the  staphyloma 
must  be  regarded  as  total. 

Treatment. — Partial  staphyloma,  without  tendency  to 
increase,  is  sometimes  best  let  alone.  Even  if  the  vision 
of  the  affected  eye  might  be  improved  by  iridectomy,  this 
will  probably  be  no  help  to  the  patient  if  he  has  good 
sight  in  the  other  eye,  unless  the  iridectomy  will  extend 
his  field  of  vision.  Otherwise,  the  imperfect  retinal 
images  gained  by  the  iridectomy  are  likely  only  to  inter- 
fere with  his  use  of  the  more  perfect  retinal  images 


308  ANTERIOR  STAPHYLOMA. 

formed  in  the  other  eye.  If,  however,  the  other  eye  is 
blind,  or  both  are  seriously  impaired,  there  is  every  reason 
to  give  the  best  sight  possible  by  doing  iridectomy  where 
it  will  allow  light  to  enter  the  eye  through  a  pupil  placed 
behind  the  clearest  and  most  regular  part  of  the  cornea. 
If  the  staphyloma  has  long  been  stationary,  and  is  not 
very  extensive,  the  iridectomy  may  be  solely  for  optical 
effect,  and  as  small  as  it  can  readily  be  made  in  the  re- 
quired situation.  If  the  staphyloma  is  at  all  progressive, 
or  is  very  large  or  quite  recent,  it  will  be  better  to  make 
a  large  iridectomy,  and  to  carry  it  well  to  the  ciliary  mar- 
gin of  the  iris  to  secure  its  utmost  influence  in  keeping 
down  intra-ocular  tension,  and  preventing  extension  of  the 
staphyloma. 

For  total  staphyloma,  nothing  can  be  done  that  prom- 
ises restoration  of  sight.  The  indications  are  simply  for 
the  prevention,  or  diminution  of  disfigurement  or  discom- 
fort. These  indications  may  also  justify  similar  opera- 
tions in  partial  staphyloma.  Tattooing  may  be  done  to  im- 
prove the  appearance  of  the  eyeball ;  or,  if  distention  is 
going  on,  incision  or  excision  may  be  practiced  (see  Chap. 
XIX).  For  a  thin  staphyloma  that  will  collapse 
when  punctured  an  incision  may  be  enough.  For  a 
thicker,  unyielding  staphyloma,  excision  of  a  portion, 
usually  the  greater  portion,  will  be  better.  Where,  in 
spite  of  this  operation,  the  tendency  to  distention  con- 
tinues, especially  if  there  is  with  it  a  tendency  to  dis- 
tention of  the  sclera,  evisceration  or  enucleation  of  the 
eye  must  be  resorted  to. 

Prognosis. — In  total  staphyloma,  restoration  of  any 
useful  vision  is  quite  impossible.  Even  light-perception 
is  likely  to  be  ultimately  lost  by  prolonged  pressure  on 
the  retina ;  and  degeneration  of  the  eyeball,  or  the  effects 
of  rupture,  may  necessitate  its  removal.  In  partial 
staphyloma,  even  a  very  small  piece  of  clear  cornea  may 
allow  restoration  from  complete  blindness  to  useful 
vision  ;  and  patients  who  are  thus  blind  appreciate  even 
slight  improvement.  But  it  must  be  remembered  that  an 
eye  with  eyen  a  small  corneal  staphyloma  is  seriously 


DISEASES  OF  THE  CORNEA.  309 

damaged,  and  especially  vulnerable  to  various  injurious 
influences. 

Keratectasia  (Ectasia  of  the  cornea)  is  a  giving  way 
of  the  cornea,  due  to  lessening  of  its  relative  resisting 
power,  by  disease  which  also  causes  corneal  opacity,  with- 
out there  having  been  a  previous  perforation  of  the  cor- 
nea, or  inclusion  of  the  iris  in  a  scar.  If  small  and 
recent,  puncture  of  the  cornea,  especially  with  the  gal- 
vanocautery,  may  be  tried.  If  extensive  and  old, 
tattooing  or  enucleation  may  be  indicated. 

Conical  Cornea  (Keratoconus.} — Disturbances  of  nu- 
trition that  attract  attention  to  the  eyes  in  no  other  way, 
may  so  weaken  the  cornea  that  it  will  give  before 
the  intra-ocular  pressure.  The  point  of  greatest  weakness, 
which  is  usually  a  little  below  the  center  of  the  cornea,  is 
forced  forward,  and  becomes  sharply  curved.  While 
around  it,  the  cornea  assumes  a  rather  conical  form.  Fig. 
99  shows  the  general  outline  of  the  cornea  in  a  section 


FIG.  99. — Diagram  of  conical  cornea.    The  dotted  lines  show  the  normal  curve 
of  the  cornea. 

through  the  apex  of  the  cone.  Conical  cornea  arises 
usually  before  the  age  of  twenty,  sometimes  after  an 
attack  of  exhausting  disease,  sometimes  under  the  strain 
of  school-work.  If  the  protrusion  is  moderate,  the  cornea 
remains  clear,  or  only  shows  a  slight  opacity  on  oblique 
illumination.  If  the  protrusion  is  extreme  (it  sometimes 
amounts  to  a  half-inch  or  more),  the  opacity  is  more 
noticeable.  The  protrusion  usually  occurs  in  both  eyes, 
and  continues  to  increase  for  a  time,  and  then  becomes 
stationary.  But  it  may  again  change  in  later  life. 


310  CONICAL  CORNEA. 

Its  most  important  effect  is  its  influence  on  the  refrac- 
tion of  the  eye.  The  apex  of  the  cone,  from  its  increased 
curvature  and  displacement  forward,  is  rendered  very 
highly  myopic ;  while  the  sides  of  the  cone,  by  their 
flattening,  balance  the  forward  displacement  so  that  toward 
the  edge  of  the  pupil  the  eye  will  be  but  slightly 
myopic,  or  even  hyperopic.  This  causes  high  aberration 
(see  p.  186),  and  the  appearance  of  the  light  and  shadow 
in  the  pupil  long  recognized  as  characteristic  of  conical 
cornea,  which  is  shown  in  Pig.  100.  The  error  of  refrac- 


Fio.  100.— The  skiascopic  appearance  in  the  high  aberration  of  conical  cornea. 

tion  always  makes  vision  imperfect,  and  only  rarely  can 
it  be  corrected  by  lenses  so  as  to  give  vision  approaching 
the  normal  standard.  The  lenses  giving  best  vision  are 
usually  strong  concave  spherical s,  combined  with  very 
strong  cylindricals.  If  the  conicity  is  of  high  degree, 
and  increasing,  it  is  proper  to  attempt  to  check  it  by 
operation.  This  may  be  the  excision  of  a  small  lens- 
shaped  piece  from  the  apex  of  the  cone,  or  by  touching 
and  perforating  the  apex  with  the  galvanocautcry. 

KeratoglobtlS. — When,  instead  of  giving  way  at 
one  part,  the  cornea  distends  uniformly  before  the  intra- 
ocular pressure,  this  condition  results.  Besides  being 
pushed  forward,  the  cornea  is  enlarged  laterally,  so  that 
it  may  be  12  or  15  mm.  in  diameter,  instead  of  the  nor- 
mal size  of  10  to  11  mm.  The  eye  looks  prominent,  the 
anterior  chamber  is  very  deep,  the  iris  looks  flat,  the 
pupil  is  small.  Usually  the  refraction  is  quite  myopic. 


DISEASES  OF  THE  CORNEA.  311 

Both  eyes  are  commonly  affected.  The  condition  may 
attract  no  special  attention,  being  regarded  simply  as  a 
personal  peculiarity.  It  develops  in  early  life.  Correc- 
tion of  the  error  of  refraction  is  the  only  treatment 
required.  Keratoglobus  is  also  a  symptom  of  buphthal- 
mos  (see  Chap.  XV). 

Tumors  originating  in  the  cornea  are  extremely 
rare,  although  it  may  be  involved  in  growths  starting  in 
the  conjunctiva,  or  penetrating  it  from  the  interior  of  the 
eye.  Dermoid  tumor  of  the  junction  of  the  cornea  and 
conjunctiva  is  riot  so  rare.  It  is  congenital,  but  may  grow 
after  birth.  It  occurs  most  frequently  at  the  temporal 
side,  lying  partly  on  the  cornea  and  partly  on  the  con- 
junctiva. It  has  the  color  and  appearance  of  a  piece  of 
skin,  and  often  presents  numerous  small  hairs,  which  may 
cause  irritation  of  the  lids.  Removal  of  the  tumor  may 
be  indicated  for  cosmetic  reasons.  It  is  done  under 
cocain  by  simply  dissecting  it  off  from  the  cornea  and 
sclera ;  and  drawing  the  conjunctiva  as  much  as  possible 
over  the  denuded  surface. 

Burns  of  the  cornea,  either  by  heat  or  caustics,  by 
causing  coagulation  and  opacity  of  the  superficial  layers, 
appear  serious,  even  when  slight.  They  may  cause  deep 
sloughing,  or,  in  connection  with  burn  of  the  conjunctiva, 
a  subsequent  symblepharon.  Those  by  lime  are  frequent 
and  serious.  They  must  be  treated  by  thorough  cleansing 
and  a  protective  dressing  (see  p.  272). 

Wounds  and  foreign  bodies  in  the  cornea  are  considered 
in  Chapter  XVII. 

DISEASES  OF  THE  SCLERA. 

Scleritis  (ficlerotitis,  flpiscleritis). — Inflammation  of  the 
sclera  occurs  from  the  causes  of  inflammation  in  white 
fibrous  tissue  in  other  parts  of  the  body,  exposure,  gout, 
rheumatism,  syphilis,  scrofula,  "  disturbed  menstruation," 
and  more  obscure  errors  of  nutrition.  Two  forms  are 
recognized,  a  superficial  (episcleritis)  and  a  deep  inflamma- 
tion. The  former  leaves  the  eye  uninjured  ;  but  the  latter 


312  SCLERITIS. 

may  extend  to  the  deeper  coats  of  the  eye,  and  by  intra- 
ocular lesions  injure  the  sight. 

Symptoms. — The  hyperemia  and  swelling  are  com- 
monly limited  to  one  or  more  round  patches,  of  a  dusky-  or 
purple-red,  due  to  deep  hyperemia,  over  which  pass  enlarged 
conjunctival  vessels.  The  affected  spot  is  decidedly 
prominent  from  the  swelling,  and  may  be  tender  to  touch. 
The  accompanying  pain  varies  greatly,  being  in  some  cases 
trifling,  in  others  very  constant  and  severe.  The  swell- 
ing and  discoloration  usually  subside  slowly  after  many 
weeks,  often  leaving  a  spot  of  bluish  discoloration,  which 
may  be  slightly  depressed,  or  which  may  become  dis- 
tended, causing  a  staphyloma.  A  marked  characteristic 
of  the  disease  is  its  tendency  to  recur  again  and  again, 
and  in  spite  of  all  treatment. 

Diagnosis. — From  phlyctenular  conjunctivitis  it  is 
distinguished  by  the  more  dusky  or  purple  color  of  the 
hyperemia,  and  its  depth,  and  chronic  course ;  and  in 
some  cases  by  the  absence  of  pain  and  photophobia,  also 
by  the  age  of  the  patient.  The  cases  of  scleritis  most 
resembling  phlyctenular  disease  occur  in  adults  or  elderly 
people.  •  From  iritis  and  keratitis,  it  is  distinguished  by 
absence  of  changes  in  the  iris  or  cornea,  except  when 
complicated  by  sclerosing  keratitis.  The  deep  cases  are 
to  be  distinguished  from  the  superficial  by  the  wide 
extent  of  the  hyperemia. 

Treatment. — Locally  bathing  the  eye  with  very  hot 
water,  and  instillations  of  atropiii  are  generally  of  benefit. 
Massage,  gentle  during  the  acute  hyperemia,  and  more 
vigorous  at  a  later  stage,  is  also  of  value.  Touching  the 
affected  part  from  time  to  time  with  the  actual  cautery 
has  been  useful  in  some  cases.  The  general  treatment  is 
equally  important.  Syphilis,  gout,  rheumatism,  or  serious 
faults  of  nutrition,  should  receive  careful  attention.  Diet, 
habits,  and  manner  of  living,  must  be  regulated  if  possi- 
ble ;  and  change  of  climate,  or  residence  at  some  spa, 
may  be  worth  trying,  in  view  of  the  liability  in  cases 
of  deep  inflammation  to  scleral  staphyloma  or  intra-ocular 
lesions  that  may  destroy  the  sight. 


DISEASES  OF  THE  SOLERA.  313 

Staphyloma  of  the  Sclera  (Partial  Sderal  Ec- 
tasid). — Weakening  of  the  scleral  coat  by  injury,  deep 
scleritis,  gumma  of  the  ciliary  body,  or  in  connection 
with  choroiditis,  may  cause  the  distention  of  the  weak- 
ened part  before  the  intra-ocular  pressure.  Or  abnormal 
increase  of  intra-ocular  tension  may  do  the  same  thing 
with  the  normal  sclera.  The  lesion  is  named  according 
to  location,  a  ciliary,  equatorial,  or  posterior  staphyloma, 
or  ectasia.  The  bulging  is  readily  perceived  anteriorly  ; 
and  by  focal  illumination,  the  thinness  of  the  sclera  may  be 
demonstrated.  Posterior  staphyloma  is  recognized  and 
studied  with  the  ophthalmoscope  (see  p.  162).  Nothing 
except  removal  of  causes  can  be  done  in  the  way  of  treat- 
ment, since  the  disturbance  of  nutrition  that  allows  such 
distention  makes  operative  interference  dangerous  or  use- 
less, unless  sight  has  been  lost.  Then  enucleation  or  some 
substitute  may  be  necessary. 

Buphthalmos  is  a  general  dilatation  of  the  sclera, 
which  begins  in  childhood,  and  usually  progresses  until 
vision  is  entirely  lost.  (See  Chap.  XV.) 

Injuries  of  the  sclera  are  considered  in  Chapter  XVII. 

BIBLIOGRAPHY. 

Diseases  of  the   Cornea   and   Sclera.      S.  M.  Burnett,   "American 

Text-Book." 
Diseases  of  the  Cornea.    J.  P.  Nuel,   "System   of  Diseases  of  the 

Eye,"  vol.  iv. 
The    Corneal    Circulation.      E.    Gruber,    "Ophthalmic    Review," 

Jan.,  1895. 
Suture  of  the  Cornea.      W.  H.  Bates,  "Archives  of  Ophthalmol.," 

March,  1898. 
Detection  of  Unsuspected  Corneal  Changes  with  Strong  Lenses  by 

Focal  Illumination.    H.  Gradle,  "Ophthal.  Kecord,"  Sept.,  1898. 
Toluidin-blue  as  a  Stain  for  Corneal  Abrasions  and  Ulcers.     C.  A. 

Veasey,  "Philadelphia  Med.  Jour.,"  Aug.  13,  1898. 
Suppurative   Keratitis.      Uhtoft"  and  Axenfeld,   "Ophthalmic   Re- 
view," June,  1896. 
Hypopyon    Keratitis.      John    Green   and   A.   E.  Ewing,   "  Trans. 

Amer.  Ophthalmol.  Soc.,"  1898. 
Serpent  Ulcer  of  the  Cornea  caused  by  the  Pneumococcus.     H.  Gif- 

ford,  "Archives  of  Ophthalmology,"  Mar.,  1898. 
Superficial  Punctate  Keratitis.     E.  Fuchs,  "Ophthalmic  Review," 

Mar,,  1890. 


314  BIBLIOGRAPHY. 

Oyster  Shucker's  Keratitis.    R.  L.  Randolph,  "  Johns  Hopkins  Hosp. 

Bull.,"  Nos.  55  and  57;  "Trans.  Amer.  Ophthal.  Soc.,"  1895. 
Dendritic  Keratitis.     W.  H.  Wilder,  "Trans.  Sect,  on  Ophthalmol., 

Amer.  Med.  Assoc.,"  1893. 

Striated  Opacity  of  the  Cornea.     W.  T.  Holmes  Spicer,  "  Royal  Lon- 
don Ophthal.  Hosp.  Rep.,"  vol.  xiv.,  part  ii. 
Filamentary   Keratitis.      Hess   and   Nuel,   "Ophthalmic  Review," 

Jan.,  1894. 
Trophic  Keratitis.     George  C.  Harlan,  "  Trans.  Amer.  Ophthalmol. 

Soc.,"  1897. 
Kerato-Globus.     George  C.  Harlan,    "Archives  of   Ophthalmol.," 

Mar.,  1898. 
Blood-staining  of  the  Cornea.     E.  T.  Collins,  "  Trans.  Ophthalmol. 

Soc.  of  United  Kingdom,"  May,  1895. 
Dermoid  Tumors  of  the  Cornea.     A.  R.  Baker,  "Trans.  Sect,  on 

Ophthalmol.,  Amer.  Med.  Assoc.,"  1896. 


CHAPTER  XI. 

DISEASES  OF  THE  IRIS,  CILIARY  BODY,  AND  CHO- 
ROID;   SYMPATHETIC   OPHTHALMIA. 

THE  iris,  ciliary  body  and  choroid,  constitute  together 
the  uveal  tract,  the  vascular,  or  nutritive  coat  of  the  eye. 
The  close  anatomical  and  physiological  relations  of  its 
different  parts  demand  that  their  diseases  should  be  con- 
sidered together,  not  only  in  the  text-book,  but  equally  in 
the  ordinary  clinical  work  of  diagnosis  and  treatment. 
Their  vital  importance  to  the  non-vascular  transparent 
tissues,  the  vitreous,  crystalline  and  aqueous,  which  de- 
pend on  the  uveal  tract  for  their  nutritive  supply,  is  also 
to  be  born  in  mind  in  connection  with  loss  of  trans- 
parency or  other  disease  in  those  tissues. 

IRITIS  AND  CYCLITIS. 

Iritis. — Causes. — Of  all  cases  of  iritis  one-half  are 
caused  by  syphilis,  one-fourth  by  rheumatism,  including 
a  group  of  allied  conditions  of  nutrition  ;  and  most  of 
the  remainder  by  gout,  traumatism,  preceding  febrile  dis- 
eases, certain  cachexias,  gonorrhea,  diabetes,  and  new 


DISEASES  OF  THE  fRIS.  315 

growths  in  the  iris,  with  a  frequency  diminishing  in  some- 
what the  order  named.  Eye-strain  is  also  a  cause  of  some 
importance.  The  conjunction  of  two  or  more  of  these 
causes  increases  the  liability  to  iritis,  although  in  many 
cases  a  conjunction  of  causes  is  not  perceptible. 

Symptoms  and  Course. — A  typical  case  of  iritis  be- 
gins with  discomfort  in  the  eye,  which  usually  increases 
to  a  distinct  ache  referred  to  the  brow  immediately  above 
the  eye.  With  this  there  is  often  increased  secretion  of 
tears,  and  the  eye  becomes  reddened.  The  hyperemia 
may  to  some  extent  involve  the  conjunctival  vessels,  espe- 
cially if  the  eye  is  kept  covered  or  bandaged  ;  but  its 
constant  characteristic  is  the  marked  pericorneal  zone  (see 
p.  61),  illustrated  in  Figs.  18  and  101.  This  zone,  com- 


FIG.  101. — Iritis  with  contracted,  irregular  pupil  and  pericorneal  zone. 

mencing  as  light  pink,  becomes  more  pronounced  as  the 
severity  of  the  attack  increases,  and  its  color  deepens 
toward  a  brick-red  or  a  dark  purplish  hue.  When  the 
pericorneal  zone  is  well  marked  there  is  generally  dis- 
coloration of  the  iris  (see  p.  71),  loss  of  luster  and  indis- 
tinctness of  its  surface,  and  contraction  of  the  pupil,  with 
irregular  dilatation  in  the  dark-room. 

As  the  case  goes  on,  the  pain  becomes  more  severe, 
being  worse  at  night,  and  preventing  sleep.  It  is  referred 
to  the  eyebrow,  nose,  or  the  whole  front  of  the  head,  is 
of  an  aching  character,  usually  severe ;  and  only  in  rare 
cases  slight  or  absent.  It  continues  until  the  height  of 
the  disease  is  passed,  and  may  be  felt  as  an  occasional 
discomfort  after  the  inflammation  has  ceased.  The  eye 
may  also  be  tender  on  pressure,  although  this  is  associated 
chiefly  with  cyclitis. 

The  pericorneal  redness  continues  usually  until  after  the 


316  SYMPTOMS  OF  IRITIS. 

pain  has  become  inconstant  or  has  passed  away.  In  the 
latter  stages  it  varies  greatly  with  the  exposure  of  the  eye 
to  irritant  influences ;  and  after  the  eye  seems  free  from 
redness,  a  little  manipulation  of  it,  or  exposure  to  air  or 
strong  light,  or  even  simply  directing  attention  to  it  by 
inspection,  may  cause  i,he  appearance  of  marked  hyperemia 
in  a  few  minutes.  Such  an  eye  is  said  to  be  irritable  ;  and 
the  condition  of  undue  irritability  may  continue  for  one 
or  two  weeks  after  the  cessation  of  constant  hyperemia. 
The  blurring  and  alteration  of  appearance  of  the  iris- 
surface  increase  with  the  severity  of  the  inflammation. 
They  are  due  to  changes  in  the  structure  of  the  iris  itself, 
particularly  its  anterior  epithelial  layer ;  and  also  to  hazi- 
ness and  discoloration  of  the  aqueous  humor  by  exuda- 
tion. 

The  contraction  and  fixity  of  the  pupil  become  more 
marked,  unless  overcome  by  a  mydriatic ;  and  its  form 
becomes  irregular.  These  changes  of  form  are  due  to 
hyperemia  of  the  iris,  exudate  into  the  iris-tissue,  and 
adhesion  of  the  iris  to  the  lens-capsule.  They  are  illus- 
trated in  Figs.  101,  102,  and  103 ;  and  are  always  most 


o 


ABC 

FIG.  102.— Iritis.  A,  with  pupil  contracted ;  -B,  with  pupil  dilated,  showing 
adhesions  of  the  iris  to  the  lens-capsule;  C,  with  pupil  dilated,  as  seen  with 
the  ophthalmoscope. 

noticeable  when  the  pupil  is  most  under  the  influence  of 
a  mydriatic.  They  should  be  studied  by  oblique  illumi- 
nation and  with  the  ophthalmoscope. 

Adhesions  between  the  lens-capsule  and  the  iris  usually 
form  first  at  isolated  points  of  the  margin  of  the  pupil ; 
but  they  may  extend  along  the  whole  pupillary  margin, 
or  to  a  large  part  of  the  posterior  surface  of  the  iris.  At 
the  points  of  adhesion  the  iris  is  prevented  from  retracting 
when  subjected  to  the  influence  of  a  mydriatic,  and  these 


DISEASES  OF  THE  IRIS.  317 

points  appear  projecting  into  the  dilated  pupil,  as  in  Fig. 
102.  In  contrast  with  the  above,  hyperemia  or  exudation 
in  a  limited  portion  of  the  iris  causes  a  rounded  projection 
into  the  pupil,  as  shown  in  Fig.  103. 


W 


o 


ABC 

FIG.  103.— Iritis,  pupil  distorted  by  local  swellings  of  the  iris.    A,  pupil  con- 
tracted; B,  pupil  dilated;  C,  as  seen  with  the  ophthalmoscope. 

The  adhesions  of  the  iris  to  the  lens-capsule,  posterior 
synechice,  are  at  first  very  weak  and  easily  broken.  Hence 
the  early  use  of  a  mydriatic  may  cause  sufficient  pull 
upon  them  to  break  them,  a  portion  of  the  exudate 
remaining  as  an  opaque  brown  spot  upon  the  lens-capsule. 
A  number  of  such  spots  often  mark  what  has  been  the 
margin  of  the  pupil  before  dilatation.  Later,  when  they 
have  become  partly  organized,  the  same  pull  may  stretch 
the  synechia ;  the  iris  retracting,  but  still  retaining  a 
connection  with  the  lens-capsule  by  a  thread  of  adhesion. 
But  the  exudate  tends  to  undergo  organization  into  firm 
connective  tissue.  When  this  has  occurred,  the  retractile 
force  of  the  iris,  even  under  the  strongest  mydriatic,  is 
unable  to  sever  or  stretch  the  synechia,  and  the  iris 


ABC 

FIG.  104.— Pupil  distorted  by  iritic  adhesions.  A,  on  first  use  of  mydriatic; 
B,  adhesions  stretched  and  one  broken  off;  C,  all  the  adhesions  broken  loose 
but  two,  leaving  a  ring  of  dots  of  exudate  on  the  lens-capsule. 

remains  permanently  bound  down.  The  effects  of  these 
different  conditions  on  the  appearance  of  the  pupil,  when 
subjected  to  a  mydriatic,  are  shown  in  Fig.  104. 

In  a  large  number  of  cases,  even  if  the  exudate  causes 


318  SYMPTOMS  OF  IRITIS. 

no  posterior  synechia,  it  appears  as  a  precipitate  on  the 
posterior  surface  of  the  cornea,  the  so-called  keraiitis 
punctata,  to  be  referred  to  under  cyclitis  (page  324). 

Although  not  a  characteristic  symptom,  impairment  of 
vision  almost  always  occurs  in  iritis.  It  is  most  constantly 
due  to  clouding  of  the  dioptric  media,  either  the  cornea 
or  the  vitreous  may  be  affected,  and  the  aqueous  is  almost 
always  altered.  Synechia?  are  also  likely  to  cause  more 
or  less  opacity  of  adjoining  portions  of  the  crystalline 
lens.  In  some  cases  the  iritis  is  followed  by  a  myopia 
which  may  last  for  several  weeks  or  months.  The  dilata- 
tion of  the  pupil  by  a  mydriatic  adds  to  the  impairment 
of  vision.  The  tension  of  the  eyeball  is  generally  not 
markedly  altered  in  acute  iritis ;  but  it  may  become  so  in 
acute  or  recurrent  attacks,  when  certain  conditions  dis- 
cussed in  Chapter  XV  arise. 

The  subsidence  of  iritis  is  shown  by  diminution  of  the 
pain  and  hyperemia,  and  better  dilatation  of  such  parts 
of  the  pupil  as  are  not  bound  down  firmly  by  the  synechia?, 
such  dilatation  depending  on  lessened  hyperemia,  or  the 
removal  of  the  exudate  from  the  tissue  of  the  iris,  or 
both.  A  renewal  of  the  inflammation  is  indicated  by 
symptoms  similar  to  those  of  the  original  attack.  Re- 
lapses are  quite  liable  to  occur,  especially  if  the  causative 
condition  has  not  been  entirely  remedied. 

Varieties. — The  form  of  iritis  described  above  is  called 
simple  or  plastic  iritis.  It  is  closely  allied  with  parenchy- 
matous  iritis,  in  which  the  exudation  being  chiefly  within 
the  tissue  of  the  iris  causes  marked  swelling.  Purulent 
iritis  is  usually  associated  with  similar  disease  of  other 
parts  of  the  uveal  tract.  It  occurs  with  acute  infectious 
diseases,  meningitis,  pneumonia,  or  pyemia.  It  may 
cause  hypopyon.  When  in  plastic  iritis  the  exudate 
is  so  abundant  that  it  coagulates,  forming  a  grayish 
mass  in  the  anterior  chamber,  which  may  be  mistaken  for 
a  dislocated  lens,  the  case  is  said  to  be  one  of  spongy, 
orfibrinous,  iritis.  Quiet  or  insidious  iritis,  occurs  chiefly 
in  anemic,  poorly-nourished  women  approaching  middle 
life.  It  is  attended  with  no  pain,  and  the  hyperemia  is 


DISEASES  OF  THE  IRIS.  319 

so  slight  as  sometimes  to  pass  unnoticed.  The  patient 
comes  for  impairment  of  sight,  and  the  iris  is  found  firmly 
bound  down  to  the  lens-capsule.  This  form  has  been 
designated  uveitis,  on  the  supposition  that  only  the  pos- 
terior or  uveal  layer  of  the  iris  is  inflamed.  The  serous 
iritis  of  older  authors  is  here  described  as  cyclitis.  Iritis 
is  also  divided  into  varieties  according  to  its  causation. 

Syphilitic  iritis  occurs  as  one  of  the  secondary  lesions 
of  that  disease,  mostly  within  the  first  year  after  the  in- 
fection. In  the  majority  of  cases  both  eyes  are  affected. 
It  always  becomes  plastic,  although  at  first  it  may  appear 
serous,  and  it  is  often  also  parenchymatous,  being  marked 
by  the  formation  of  small  papules  or  condylomata  near 
the  margin  of  the  pupil.  A  rather  similar  form  appears 
in  hereditary  syphilis  during  the  first  year  of  life.  An 
iridocyclitis  often  accompanies  interstitial  keratitis,  or  it 
may  occur  alone  as  a  tertiary  lesion  of  acquired  or  in- 
herited syphilis.  More  or  less  iritis  attends  the  forma- 
tion of  gumma  in  the  iris  (see  page  330).  Syphilitic  iritis 
properly  treated  is  not  especially  liable  to  recur. 

Rheumatic  iritis  may  accompany  an  outbreak  of  acute 
articular  rheumatism,  may  alternate  with  attacks  of  sub- 
acute  rheumatism,  or  may  occur  after  special  exposure  as 
the  only  manifestation  of  the  diathesis.  It  is  attended 
with  severe  pain  and  hyperemia,  often  affects  but  one  eye, 
and  is  especially  liable  to  recur.  It  is  marked  by  the 
early  formation  of  synechiae,  which,  however,  are  narrow 
and  easily  torn  asunder  or  stretched  under  the  influence 
of  a  mydriatic. 

Gouty  iritis,  arthritic  ophthalmia,  resembles  rheumatic 
iritis,  but  is  usually  less  violent.  It  is  accompanied  by 
cyclitis,  and  often  by  a  dilated  tortuous  condition  of  the 
conjunctival  vessels. 

Gonorrheal  iritis  may  occur  with  acute  gonorrheal 
rheumatism,  as  a  violent  plastic  iritis  ending  in  recovery, 
with  comparative  freedom  from  sequels.  Or  it  may 
occur  at  a  later  stage  as  a  less  violent  iritis  with  a  strong 
tendency  to  relapse.  Diabetic  iritis  is  marked  by  ex- 
tensive exudate,  which  is  usually  fibrinous  but  may  be 


320  VARIETIES  OF  IRITIS. 

purulent,  and  which  generally  clears  up  very  well  under 
treatment.  The  possibility  of  diabetes  should  be  borne 
in  mind  in  all  cases  of  iritis  of  obscure  causation.  Oph- 
thalmia nodosa  may  involve  the  iris  with  the  formation 
of  nodules  in  its  tissue  (see  page  243). 

Traumatic  iritis  may  arise  from  direct  injury  or  the 
lodgement  of  a  foreign  body  in  the  iris ;  or  it  may  follow 
bruise  without  any  perceptible  lesion  within  the  eyeball. 
New  growths  involving  the  iris  generally  give  rise  to 
inflammation.  Glaucoma  of  the  inflammatory  type  is 
constantly  attended  by  iritic  inflammation.  Inflamma- 
tions of  the  cornea,  as  well  as  those  of  the  ciliary  body 
and  choroid,  are  liable  to  involve  the  iris. 

Diagnosis. — The  diagnosis  of  iritis  rests  on  visible 
changes  in  the  iris.  A  careful  examination  of  the  eye  by 
oblique  illumination  and  with  the  ophthalmoscope,  and  the 
careful  testing  of  mobility  of  the  iris  and  pupil  are  essen- 
tial. It  is  to  be  distinguished  from  cyditis  by  the  absence 
in  the  latter  of  changes  in  the  iris  itself,  although  the 
other  symptoms  of  iritis  are  present.  Keratitis  is  dis- 
tinguished from  iritis  by  discovering  changes  in  the  cor- 
nea, such  as  haziness,  localized  opacity  or  ulceration, 
without  alteration  in  the  iris,  except  such  change  of  color, 
and  blurring  of  detail  as  the  corneal  haze  would  cause. 
When  keratitis  occurs  in  an  eye  presenting  alterations  of 
the  iris  due  to  a  preceding  iritis,  or  iritis  attacks  an  eye 
having  corneal  opacities  or  irregularities,  the  differential 
diagnosis  may  be  impossible. 

In  conjunctivitis  the  redness  is  conjunctival  (Fig.  16)  or 
phlyctenular  (Fig.  17),  not  pericorneal  (Fig.  18) ;  the 
pain  is  smarting,  burning  or  the  feeling  of  a  foreign  body, 
not  aching;  and  is  confined  to  the  eye,  not  referred  to 
the  brow,  nose  or  cheek  as  in  iritis ;  the  iris  is  unaltered 
in  appearance  or  reaction ;  and  the  vision  is  generally 
unaffected.  The  differential  diagnosis  from  glaucoma  is 
extremely  important.  It  is  discussed  in  connection  with 
that  affection  (Chapter  XV). 

When  iritis  follows  trail matism,  one  must  make  sure 
that  it  does  not  mask  more  serious  lesions.  And  as  it 


DISEASES  OF  THE  IEIS.  321 

attends  new  growths  in  the  iris  and  in  deeper  parts  of 
the  eye,  the  recognition  of  the  iritis  must  not  prevent  the 
search  for  such  more  serious  causes.  The  diagnosis  of 
the  different  varieties  of  iritis  rests  on  points  mentioned 
in  describing  them. 

Treatment. — The  treatment  of  iritis  includes :  the 
removal  or  treatment  of  its  cause,  the  subjection  of  the 
iris  to  the  influence  of  a  strong  mydriatic,  the  relief  of 
pain,  antiphlogistic  measures,  and  the  improvement  of 
the  general  health  and  nutrition. 

General  Treatment. — Mercury  is  of  special  value  in 
plastic  iritis.  The  author  prefers  to  begin  with  calomel 
in  doses  of  -|  to  i-  grain,  three  or  four  times  a  day,  con- 
tinued until  they  produce  a  decided  eifect  on  the  bowels, 
or  other  evidence  of  the  general  action  of  the  drug.  After 
this  the  mercury  may  be  continued  in  a  different  form 
(see  Chapter  XVIII),  for  syphilis,  or  discontinued  in 
the  non-syphilitic.  Where  rheumatism  is  the  cause,  saly- 
cilates  should  be  given  freely.  The  patient  should  keep 
dry  and  warm,  and  the  Turkish  bath,  or  exposure  of  the 
surface  to  superheated  air  may  be  beneficial.  The  diet 
should  be  regulated  to  the  exclusion  of  whatever  is  im- 
perfectly digested.  A  gouty  iritis  requires  regulated 
diet,  excluding  all  alcoholic  drinks,  acid  fruits,  and  all 
articles  known  to  have  produced  previous  gouty  attacks, 
and  much  meat.  Alkalies  and  alkaline  waters  may  be 
given  freely,  with  colchicum,  or  piperazin.  For  iritis  in 
the  diabetic,  the  regulation  of  the  diet  becomes  of  chief 
importance.  Gonorrhea!  iritis  should  be  treated  much 
like  that  due  to  rheumatism,  with  the  addition  of  careful 
attention  to  any  urethral  discharge.  Malarial  iritis  re- 
quires quinin  in  large  doses,  and  sometimes  arsenic. 

Many  who  suffer  from  iritis  are  distinctly  anemic  and 
poorly  nourished,  or  even  cachectic.  Such  patients 
should  have  tincture  of  chlorid  of  iron  in  full  doses, 
and  tonic  doses  of  the  cinchona  alkaloids.  In  its  later 
stages  plastic  iritis  is  often  benefited  by  the  internal  use 
of  moderate  doses  of  potassium  iodid.  If  the  iritis  be 
violent,  the  patient  will  do  best  to  remain  in  bed.  In 
21 


322  TREATMENT  OF  IRITIS. 

any  case  he  should  avoid  fatigue  or  exposure.  Sudden  or 
great  changes  of  light  must  be  avoided  ;  but  confinement 
in  absolute  darkness  is  not  usually  necessary  or  advan- 
tageous. 

Local  Treatment. — The  eye  should  be  brought  quickly 
and  completely  under  the  influence  of  one  of  the  stronger 
mydriatics.  Atropin  is  probably  best,  because  of  the 
slower  recovery  from  it,  and  its  slighter  tendency  to 
cause  constitutional  symptoms.  Its  action  may  be  greatly 
assisted  and  hastened  by  the  simultaneous  instillation  of 
cocain  (see  Chapter  XVIII).  Since  it  is  of  great  im- 
portance to  secure  dilatation  of  the  pupil,  and  the  danger 
of  mydriatic  intoxication  limits  the  amount  of  the  drug 
that  can  be  used  at  one  time,  it  is  often  well,  even  when 
both  eyes  are  affected,  to  make  the  chief  mydriatic  attack 
on  one  eye  one  day,  and  the  other  the  next.  The  cocain 
is  to  be  used  in  such  a  mydriatic  attack.  If  a  good  dila- 
tation of  the  pupil  be  not  secured  at  first,  it  may  be  well 
to  repeat  the  mydriatic  attack  a  few  days  later,  when  the 
use  of  mercury  may  have  weakened  the  adhesions,  or 
may  have  reduced  the  hyperemia  or  exudation  in  the  iris. 
After  the  best  dilatation  of  the  pupil  has  been  obtained, 
it  is  to  be  kept  up  by  the  use  of  so  much  of  the  mydriatic 
as  may  be  necessary.  This  may  require  at  first  the  use 
of  the  strong  solution  four  to  six  times  a  day.  Later,  a 
weaker  solution  may  be  used,  and  one  to  three  instilla- 
tions may  suffice.  The  use  of  the  mydriatic  should  usually 
be  continued  until  the  eye  is  entirely  free  from  redness, 
or  irritability.  A  few  cases  of  iritis,  usually  complicated 
with  severe  cyclitis,  do  better  if  the  mydriatic  is  discon- 
tinued early,  as  after  two  or  throe  days. 

Next  in  importance  is  the  local  application  of  heat. 
Cold  may  be  of  benefit  in  traumatic  cases  during  the  first 
twenty-four  hours  after  the  injury,  but  otherwise  it  does 
little  good  in  iritis.  Hot  applications  are  better.  These 
may  be  by  bathing  the  eye  and  surrounding  parts  with 
water  as  hot  as  can  be  borne,  immediately  before  the  in- 
stillation of  the  mydriatic,  or  when  the  eye  becomes 
especially  painful ;  or  the  continuous  use  of  dry  heat  by 


DISEASES  OF  THE  IRIS.  323 

means  of  the  hot-water  coil  or  the  Japanese  hot-box. 
Heat  has  a  powerful  influence  in  lessening  pain ;  and  the 
brief  application  of  strong  heat  causes  contraction  of  the 
vessels,  diminishing  hyperemia. 

Local  bleeding  from  the  temple,  either  by  the  natural 
or  the  artificial  leech,  also  controls  pain ;  and  is  often  the 
starting  point  for  progressive  improvement.  It  is  of  use 
chiefly  in  the  more  acute  cases  attended  with  acute  pain. 
It  may  be  repeated  on  successive  days,  or  even  more  fre- 
quently, if  the  pain  recurs  (see  Chapter  XVIII).  In 
general,  the  eye  should  not  be  bandaged,  unless  this  is 
needful  to  protect  it  against  severe  cold. 

If  the  relief  of  pain  be  not  eifected  by  the  local  treat- 
ment, it  may  be  best  to  give  analgesics,  like  opium,  or 
acetanilid,  a  little  before  bed-time  to  secure  as  much  sleep 
as  possible ;  for  loss  of  sleep  may  seriously  hinder  reso- 
lution. For  the  sequels  of  iritis  see  page  326. 

Prognosis. — When  an  iritis  is  seen  early,  the  patient 
should  be  warned  of  the  serious  nature  of  the  attack,  the 
danger  of  permanent  damage  by  iritic  adhesion,  that  the 
eye  is  likely  to  become  more  inflamed  and  painful  before 
it  begins  to  get  better,  and  that  several  weeks  or  months 
may  be  required  for  complete  recovery.  The  results  of 
an  attack  depend  largely  on  treatment ;  but  also  upon 
constitutional  conditions  that  cannot  be  exactly  appre- 
ciated. While  partial  restoration  to  normal  generally 
occurs,  complete  restoration  is  exceptional.  Recurrence 
and  relapse  are  most  common  in  the  insidious  iritis  of  the 
cachectic,  especially  of  anemic  women.  They  are  also 
common  in  rheumatic  and  gouty  iritis.  They  are  rare 
after  well-treated  syphilitic  iritis.  Although  the  recovery 
of  the  iris  maybe  complete,  concomitant  lesions,  as  of  the 
cornea,  ciliary  body  and  the  choroid,  may  cause  perma- 
nent damage.  An  attack  of  even  simple  iritis  may  lead 
to  such  changes  or  sequels  as  will  totally  destroy  the  use- 
fulness of  the  eye.  Yet  sometimes  an  eye,  blind  as  the 
result  of  iritis,  may  be  restored  to  great  usefulness  by  proper 
operative  treatment.  In  few  diseases  is  an  early  positive 


324  PROGNOSIS  OF  IRITIS. 

definite  statement  as  to  the  ultimate  result  more  rash  and 
worthless. 

Cyclitis  (Serous  Iritis,  Iridocyclitis,  Keratitis  Punc- 
tata). — Most  cases  of  iritis  show  some  extension  of  in- 
flammation to  the  ciliary  body  ;  and  in  but  few  cases  of 
cyclitis  does  the  iris  entirely  escape.  Yet  some  points 
regarding  cyclitis  should  be  considered  separately. 

Symptoms,  Causes  and  Varieties. — The  severe  pain 
and  pericorneal  hyperemia  resemble  those  of  iritis,  and 
the  vision  is  impaired,  equally  or  to  a  greater  extent,  on 
account  of  opacities  in  the  vitreous.  In  severe  acute 
cyclitis  the  ciliary  region  becomes  very  tender  to  touch. 
The  causes  are  the  same  as  those  of  iritis,  but  traumatism, 
eye-strain  and  syphilis  are  relatively  more  important. 
The  recognized  varieties  are  about  like  those  of  iritis. 
In  plastic  cyclitis  there  is  exudate  into  the  ciliary  body 
and  the  vitreous,  with  great  danger  of  subsequent  cicatri- 
cial  changes.  Purulent  cyclitis  is  associated  with  puru- 
lent choroiditis  (see  page  343). 

The  most  characteristic  symptom  is  the  deposit  of  exu- 
date on  the  posterior  surface  of  the  cornea,  usually  called 
keratitis  punctata.  The  deposit  consists  of  cells,  fibrinous 
material,  and  micro-organisms.  It  is  distributed  usually 
in  isolated  dots  arranged  in  a  triangle,  with  its  base  at 
the  lower  margin  of  the  cornea,  and  its  apex  upward. 
This  is  shown  in  Fig.  105.  The  dots  are  larger  and 
closer  together  in  the  lower  part  of  this  space ;  and  if 
there  is  a  large  amount  of  exudate  they  coalesce,  forming 


A  B 

FIG.  105.— Deposits  on  posterior  surface  of  the  cornea,  so-called  keratitis 
punctata:  .4,  as  seen  by  oblique  illumination  (the  spots  are  never  white,  but 
gray  or  even  dark  brown);  and  B,  as  seen  with  the  ophthalmoscope. 

irregular  masses.     At  first  the  cornea  on  which  they  are 
deposited  is  unaltered.     But  if  they  remain  long  in  con- 


DISEASES  OF  THE  CILIARY  BODY.  325 

tact  with  it,  each  spot  gives  rise  to  opacity  in  the 
posterior  layer  of  the  cornea  itself,  which  may  remain 
permanently.  Deposits  of  similar  material  sometimes 
occur  on  the  anterior  surface  of  the  iris  and  lens-capsule. 

The  pupil  in  cyclitis  may  be  somewhat  sluggish,  but  is 
not  contracted  unless  some  iritis  or  hyperemia  of  the  iris 
is  present.  The  periphery  of  the  iris  may  be  retracted, 
increasing  the  depth  of  the  anterior  chamber,  especially 
late  in  plastic  cyclitis. 

The  tension  of  the  eyeball  is  apt  to  be  slightly  increased 
in  the  early  stages  of  the  cyclitis,  and  much  elevated  if 
secondary  glaucoma  supervenes.  In  chronic  cyclitis 
without  glaucoma  the  tension  is  often  much  lowered. 

Diagnosis. — Cyclitis  may  be  recognized  by  the  same 
symptoms  as  iritis,  with  the  spots  of  exudate  on  the 
posterior  surface  of  the  cornea,  and  the  tenderness  of  the 
ciliary  region.  Without  these  latter  the  case  may  be 
regarded  as  one  of  iritis  without  cyclitis.  On  the  other 
hand,  if  in  spite  of  the  other  symptoms  the  iris  presents 
no  visible  alteration,  the  case  must  be  classed  as  cyclitis 
without  iritis.  Probably  the  myopia  often  observed  after 
iritis  depends  rather  on  the  changes  in  the  ciliary  body. 
In  some  cases  of  iritis,  neither  marked  changes  in  the  iris, 
nor  the  formation  of  synechise  occur  for  several  days,  the 
case  at  first  appearing  like  cyclitis.  But  in  such  cases  it  will 
be  found  that  mydriatics  show  less  power  to  dilate  the 
pupil  than  in  the  normal  eye,  on  account  of  hyperemia 
already  existing  in  the  iris.  Syphilitic  iritis  often  shows 
this  peculiarity.  Cyclitis  is  liable  to  be  confused  with 
keratitis,  and  conjunctivitis,  and  most  of  what  has  been 
said  of  the  differentiation-  of  these  affections  from  iritis 
will  apply  here.  It  must  also  be  distinguished  from 
glaucoma  (see  Chapter  XV). 

Treatment. — This  is  the  same  as  the  treatment  of 
iritis,  except  in  respect  to  the  use  of  mydriatics.  Most 
cases  of  cyclitis  complicated  with  iritis  do  well  under  a 
mydriatic.  Some  cases  of  simple  cyclitis  are  equally 
benefited  by  mydriatics.  But  a  few  cases  of  cyclitis  do 
badly  under  a  mydriatic.  Hence  mydriatics  must  be 


326  TREATMENT  OF  CYCLITIS. 

used  cautiously,  and  sometimes  discarded  altogether.  On 
this  account  the  briefer  mydriatics,  duboisn,  hyoscyamin 
and  scopolamin,  are  decidedly  preferable  to  atropin, 
and  even  homatropin  may  be  preferred  for  tentative  use 
in  simple  cyclitis. 

Prognosis. — Cyclitis  is  more  dangerous  than  simple 
iritis,  and  the  prospect  of  serious  permanent  injury  to  the 
eye  increases  with  the  severity  and  duration  of  the  attack, 
especially  with  the  amount  of  ciliary  tenderness  and 
hyperemia,  and  the  extent  of  exudation  into  the  vitreous 
as  shown  by  its  opacity. 

SEQUELS  OF  IRITIS  AND  CYCLITIS. 

The  gravity  of  iritis  is  due  chiefly  to  the  permanent 
lesions  caused  by  it  which  rise  into  prominence  as  the 
inflammation  of  the  iris  subsides. 

Myopia  following  iritis  is  observed  as  soon  as  the 
media  become  sufficiently  clear,  after  the  subsidence  of 
the  inflammation.  It  continues  to  diminish,  and  after 
several  weeks  or  months  it  passes  away,  the  refraction 
becoming  about  the  same  as  it  had  been  previous  to  the 
attack.  It  may  recur  with  recurrences  of  the  iritis.  It 
is  mostly  noticed  in  eyes  previously  but  slightly  myopic 
or  hyperopic.  In  eyes  highly  hyperopic  the  hyperopia  is 
commonly  temporarily  diminished.  These  changes  of 
refraction  should  be  met  by  prolonged  use  of  a  mydriatic, 
and  by  the  adaptation  and  proper  changes  of  lenses. 

Posterior  Synechiae. — A  few  adhesions  of  the  iris 
to  the  lens-capsule  may  be  attended  with  no  serious  con- 
sequences, particularly  if  they  are  slender,  and  stretch 
sufficiently  to  allow  pretty  free'  movement  of  the  iris  ;  and 
are  placed  outside  the  limits  of  the  contracted  pupil,  us 
they  are  apt  to  be  when  the  pupil  has  been  kept  under 
the  influence  of  a  mydriatic  during  the  height  of  the 
iritis.  Such  bands  tend  to  become  more  yielding  and 
thinner  with  time,  and  may  cease  entirely  to  interfere 
with  the  movements  of  the  iris. 

If,  however,  a  broad  unyielding  adhesion  is  located  near 
the  center  of  the  lens-capsule,  as  it  will  be  if  a  mydriatic 


SEQUELS  OF  IRITIS  AND  CYCLITIS.  327 

has  not  been  used,  it  interferes  with  the  entrance  of  light 
through  the  pupil,  and  exerts  a  continuous  traction  on 
both  the  lens-capsule  and  the  iris.  The  drag  on  the  cap- 
sule affects  the  curvature  of  the  adjoining  portions  of  the 
lens-surface,  causing  irregular  astigmatism  ;  and  disturbs 
the  nutrition  of  the  part,  so  that  a  limited  opacity  of  the 
lens  results,  interfering  still  farther  with  the  light  enter- 
ing the  pupil.  The  drag  on  the  iris  tends  to  cause 
renewed  attacks  of  iritis.  These  are  usually  less  acute 
than  the  primary  attack.  But  since  the  iris  is  bound 
down  to  start  with,  whatever  exudation  occurs,  tends  to 
extend  its  adhesion  and  cripple  it  still  farther.  In  this 
way  the  condition  of  the  iris  tends  from  bad  to  worse, 
until  one  or  the  other  of  the  graver  conditions  that  are 
liable  to  fellow  iritis  is  brought  about. 

Various  operations  for  freeing  the  iris  have  been  devised 
and  practiced  with  good  results.  In  the  best  of  these, 
the  iris  is  freed  from  its  adhesions,  either  with  a  blunt 
hook,  or  by  seizing  and  pulling  it  with  delicate  forceps, 
corelysis,  care  being  taken  to  avoid  rupture  of  the  lens- 
capsule.  But  operations  for  posterior  synechia  are  not 
often  undertaken  unless  the  indications  are  urgent,  and 
the  adhesions  broad  and  firm  ;  in  which  case  iridectomy 
is  the  better  procedure.  Usually  such  an  operation  should 
be  done  only  when  the  eye  has  been  for  some  time  quite 
free  from  hyperemia.  But  indications  may  arise  so 
urgent  as  to  justify  operation  on  an  acutely  inflamed  iris. 

Occlusion  of  the  Pupil. — In  rare  cases  of  plastic 
iritis,  free  deposit  of  fibrinous  exudate  from  the  aqueous 
covers  the  lens-capsule  over  the  whole  area  of  the  pupil, 
forming  a  gray  membrane ;  and  partial  occlusion  is  more 
common.  This  membrane  remains,  permanently  occluding 
the  pupil  and  greatly  interfering  with  vision.  Even  a 
gray  fringe  at  one  side  of  the  pupil  may  interfere  greatly 
with  vision.  Occlusion  is  to  be  treated  by  making  an 
artificial  pupil  by  iridectomy,  when  the  eye  has  become 
free  from  signs  of  irritation. 

Exclusion  of  the  Pupil  (Annular  Posterior 
Synechice). — When  the  whole  pupillary  margin  of  the  iris 


328 


EXCLUSION  OF  THE  PUPIL. 


FIG.  106.— Ballooning  of  the 
iris  (after  Nettleship). 


is  bound  down  to  the  anterior  capsule  of  the  lens,  not  only 
do  the  effects  of  broad  adhesions  occur,  but  the  escape 
of  fluid  from'  the  posterior  to  the 
anterior  chamber  is  interrupted  (see 
Chapter  XV),  and  other  grave  con- 
ditions arise.  The  fluid  behind  it 
pushes  the  iris  forward,  causing  it 
to  bulge,  as  in  Fig.  106.  This  is 
spoken  of  as  ballooning  of  the  iris 
(iris  bombe).  The  iris  rises  up  on 
either  side  of  the  pupil,  usually  not 
equally  all  round,  but  in  swellings 
separated  by  depressions  where  it 
is  bound  down  by  adhesions.  In 
the  midst  of  these  elevations  of 
the  iris  the  pupil  appears  depressed 
and  is  spoken  of  as  crater-like  pupil. 
With  the  absence  of  its  normal  movements,  and  under 
the  pressure  to  which  it  is  subjected,  the  iris  generally 
undergoes  atrophy.  Its  forward  displacement  at  the 
periphery  is  liable  to  bring  it  in  contact  writh  the  cornea, 
closing  the  angle  of  the  anterior  chamber  and  causing 
a  secondary  glaucoma.  (See  Chapter  XV.) 

Such  an  eye,  if  left  to  itself,  is  almost  certain  to  undergo 
degenerative  changes  that  will  render  it  hopelessly  blind. 
Irideetomy  should  be  done  upon  it  as  soon  as  possible, 
and  repeated,  if  necessary  to  establish  a  free  permanent 
communication  between  the  anterior  and  posterior  cham- 
ber. Irideetomy  should  be  done  even  though  the  excluded 
pupil  be  perfectly  clear,  and  the  vision  still  good. 

Total  posterior  synechia  is  the  condition  in  which 
not  only  the  margin  of  the  pupil,  but  the  whole  central 
posterior  surface  of  the  iris,  is  firmly  adherent  to  the  lens- 
capsule.  It  may  follow  a  single  severe  attack  of  plastic 
iritis  untreated  with  a  mydriatic,  but  commonly  it  fol- 
lows repeated  relapses,  especially  of  insidious  iritis.  It 
may  cause  the  whole  anterior  chamber  to  be  shallow. 
But  there  are  no  local  bulgings  like  those  of  "  iris 
bombe,"  and  the  pupil  presents  no  crater-like  depres- 


SEQUELS  OF  IRITIS  AND  CYCLITIS.          329 

sion.  Rather  the  iris  around  the  pupil  appears  thin  and 
flattened. 

In  most  cases,  accompanying  changes  in  the  deeper  parts 
of  the  eye  have  caused  diminished  intra-ocular  tension, 
and  hopeless  blindness.  When,  however,  good  perception 
of  light  remains,  some  vision  may  be  preserved;  or 
farther  degenerative  changes  in  the  eyes  may  be  pre- 
vented by  iridectomy.  This,  however,  must  be  accom- 
panied by  removal  of  the  crystalline  lens,  although  it 
may  still  be  clear.  In  total  synechia,  it  is  commonly  im- 
possible to  remove  any  considerable  piece  of  the  iris  and 
make  a  free  opening  into  the  posterior  chamber,  which  is 
obliterated  except  at  its  periphery,  without  also  removing 
the  adherent  lens-capsule ;  and  any  injury  to  the  capsule 
causes  such  opacity  and  swelling  of  the  lens,  unless  it  be 
promptly  removed,  as  would  make  the  operation  very 
harmful,  rather  than  beneficial.  Extraction  of  the  lens 
must  be  done  to  render  successful  the  operation  of  iridec- 
tomy. 

Atrophy  and  Degeneration  of  the  Iris. — Pro- 
tracted or  repeated  attacks  of  iritis,  numerous  and  firm 
synechise,  exclusion  of  the  pupil  and  total  synechia,  are 
likely  to  be  succeeded  by  degenerative  changes  in  the 
iris.  The  surface  loses  its  normal  inequalities  and  luster, 
becomes  comparatively  uniform  and  dull,  and  of  a  gray- 
ish color.  The  iris  is  thinned,  its  proper  tissue  atrophied. 
With  these,  corresponding  changes  occur  in  other  portions 
of  the  uveal  tract ;  and  such  an  appearance  of  the  iris  is 
a  most  unfavorable  sign  as  to  the  condition  of  the  deeper 
parts  of  the  eye. 

Sometimes  without  general  degenerative  changes, 
atrophy  of  a  particular  part  of  the  iris  may  occur. 
Thus  after  exclusion  of  the  pupil  in  early  childhood, 
complete  atrophy  of  certain  parts  leaves  gaps  in  the  iris- 
tissue,  resembling  congenital  polycoria.  Thinning  of  the 
iris  by  absorption,  until  the  red  fundus-reflex  can  be 
readily  seen  through  it,  may  occur  after  the  disappearance 
of  local  deposits  in  the  iris,  especially  after  gumma ;  or 
it  may  occur  after  bruising  or  stretching  of  the  iris,  as  in 


330  DEGENERATION  OF  THE  IRIS. 

cataract  extraction;    or  in  elderly  people  without  any 
history  of  previous  disease  or  injury. 

NEW  GROWTHS  IN  THE  IRIS  AND  CILIARY  BODY. 

Gumma  of  the  Iris  and  Ciliary  Body.— In  iritis 
occurring  as  a  secondary  symptom  of  syphilis  there  are 
often  (some  writers  say  always)  small  temporary  papules, 
granules,  or  condylomata,  situated  near  the  pupil,  which 
break  down,  sometimes  giving  rise  to  visible  debris  in 
the  anterior  chamber.  In  the  tertiary  stage  gummata  in 
the  form  of  large  rounded  masses,  like  those  shown  in 
Fig.  107,  appear  in  the  iris,  with  severe  iritis.  These 
undergo  absorption  under  treatment  for  syphilis,  leaving 
distinct  scars  in  the  iris.  Gumma  arising  in  the  ciliary 
body  is  attended  with  cyclitis,  and  may  cause  marked  dis- 
placement of  the  iris,  or  staphyloma  of  the  ciliary  region 
and  corneal  astigmatism.  It  should  receive  the  .same 
treatment  as  gumma  elsewhere,  except  that  mercury  is 
relatively  more  important  than  potassium  iodid. 

Tuberculosis  of  the  iris  occurs  before  the  age  of 
twenty.  It  begins  as  isolated  nodules  in  the  iris-tissue, 
each  surrounded  by  minute  vessels.  The  iris  is  swollen 
and  inflamed  throughout.  The  general  appearance  is 
illustrated  by  Fig.  108.  The  individual  deposits  may 


FIG.  107.— Gumma  of  the  iris,  the  FIG.  108.— Tuberculosis  of  the  iris, 

new  growths  seen  as  rounded  prom-  the  tubercles  showing  as  small  light 

Inences  of  lighter  color,  below  the  prominences.   Some  pericorueal  hy- 

pupil.  peremia. 

continue  to  grow  until  several  millimeters  in  diameter; 
or  they  may  undergo  absorption,  and  be  followed  by  a 
fresh  crop.  Occasionally  but  a  single  growth  appears 
(granuloma  of  the  iris),  which  may  increase  in  size  and 


TUMORS  OF  IRIS  AND  CILIARY  BODY.         331 

destroy  the  eye.  In  rare  cases  the  growths  finally  dis- 
appear leaving  the  eye  with  good  sight  and  the  patient 
free  from  tubercular  lesions.  Mostly  the  eye  is  destroyed, 
and  the  patient  succumbs  to  general  tuberculosis.  The 
treatment  is  the  general  treatment  for  tuberculosis  and 
iritis. 

Sarcoma  of  the  Iris  or  Ciliary  Body. — Sarcoma 
in  the  iris  starts  as  a  single  brown  mass  which  at  first 
grows  very  slowly,  If  not  much  pigmented,  vessels  may 
be  traced  upon  it.  Frequent  hemorrhage  may  occur. 
If  it  starts  behind  the  iris,  it  becomes  adherent  to  it; 
and,  carrying  it  away  from  its  ciliary  attachment,  causes 
an  iridodialysis.  It  is  most  common  in  early  adult  life, 
but  may  occur  at  any  period.  After  a  period  of  slow 
growth  which  may  last  for  years,  sarcoma  causes  inflam- 
mation and  increased  tension  of  the  eyeball,  breaks 
through  the  sclero-corneal  coat,  and  terminates  in  a 
rapidly  growing  tumor  and  death.  In  a  few  cases  the 
growth  has  been  removed  with  the  segment  of  the  iris 
from  which  it  springs,  and  has  not  recurred.  More  fre- 
quently the  whole  eyeball  must  be  excised,  or  if  it  has 
penetrated  the  sclera  the  whole  contents  of  the  orbit 
should  be  removed,  as  for  sarcoma  of  the  choroid. 

Carcinoma  of  the  iris  or  ciliary  body  is  very  rare. 

Benign  Tumors. — A  congenital  projection  of  the 
uveal  layer  of  the  iris  forward  through  the  pupil,  such  as 


FIG.  109.— Cyst  of  the  iris  occupying  the  lower  outer  part  of  the  anterior 

chamber. 


is  normal  in  the  eye  of  the  horse,  is  called  ectropion  of  the 
uvea.  It  appears  as  one  or  more  chocolate-brown  nodules 
on  the  pupillary  margin. 

Minute  benign  pigmented  growths,  melanomata,  some- 


332  BENIGN  TUMORS. 

times  occur  in  the  iris.  Cyst  of  the  iris  is  a  gray  round 
translucent  tumor  having  much  the  appearance  repre- 
sented in  Fig.  109.  It  consists  of  a  thin  transparent  wall, 
containing  a  serous  fluid.  An  epidermoid  pearl  or  pearl- 
cyst  of  the  iris  is  a  small  white  slowly-growing  mass  of 
epithelial  or  atheromatous  material.  Both  cysts  and 
epidermoids  disturb  and  injure  adjoining  tissues  by  press- 
ure, and  if  undisturbed  may  cause  glaucoma.  They 
commonly  start  from  some  injury,  especially  the  implan- 
tation upon  the  iris  of  a  cilium,  or  a  piece  of  epithelium 
from  the  skin  or  conjunctiva.  They  should  be  excised. 
A  few  cases  of  vascular  tumor  of  the  iris  are  recorded. 

MOTOR  DISORDERS  OF  THE  IRIS  AND  CILIARY 
MUSCLE. 

The  normal  reactions  of  the  pupil  and  their  alterations 
by  disease  have  already  been  described  (page  72),  and  are 
further  referred  to  in  Chapter  XX.  Persistent  dilatation 
of  the  pupil  from  whatever  cause,  is  called  mydriasis. 
The  most  frequent  cause  of  mydriasis  is  the  use  of  a 
mydriatic.  It  may  be  placed  in  the  patient's  eye  without 
his  knowledge,  as  by  a  contaminated  dropper  ;  or  he  may 
use  it  and  den/  it.  The  amount  required  to  produce 
mydriasis  is  so  minute  that  it  may  be  splashed  into  the 
eye,  causing  unilateral  mydriasis ;  or  taken  in  medicine 
or  food  quite  unconsciously,  when  it  will  cause  equal 
dilatation  of  both  pupils. 

Persistent  contraction  of  the  pupil  is  called  myosis. 
It  may  also  be  caused  by  drugs,  especially  eserin  (physos- 
tigmin)  or  pilocarpin  locally, /and  opium  internally. 
Various  conditions  of  the  iris,  especially  moderate  hyper- 
emia,  also  cause  it.  Exaggeration  of  the  normal  alternat- 
ing contraction  and  dilatation  of  the  pupil  on  passing 
from  a  dim  to  a  bright  light  is  hippm.  Tremulousness 
of  the  iris,  when  the  iris  loses  the  support  of  the  crystal- 
line lens,  is  called  iridodonesis. 

Cycloplegia,  paralysis,  or  paresis  of  accommodation, 
paralysis,  or  paresis  of  the  ciliary  muscle,  is  to  be  sharply 
distinguished  from  presbyopia,  although  their  symptoms 


IRIS  AND  CILIARY  MUSCLE.  333 

are  in  some  respects  precisely  alike.  The  former  is  loss 
of  power  in  the  muscle,  an  inability  to  influence  the  still 
flexible  lens,  a  true  paralysis  or  paresis.  The  latter  arises 
from  increased  resistance  of  the  lens,  limiting  the  effect 
produced  upon  it  by  the  normal  ciliary  muscle.  Pres- 
byopia comes  on  imperceptibly,  and  rarely  or  never 
diminishes.  Paralysis  of  accommodation  may  be  entirely 
sudden  ;  even  when  most  gradual  it  changes  notably  from 
month  to  month ;  and  it  may  end  in  partial  or  complete 
recovery. 

Causes  and  Varieties. — The  most  frequent  cause  is 
the  influence  of  a  cycloplegic  drug,  which,  at  the  same 
time,  produces  dilatation  of  the  pupil.  Diphtheritic  par- 
alysis of  the  accommodation  comes  on  at  the  third  to  the 
sixth  week  from  the  onset  of  the  disease,  and  lasts  from 
a  few  days  to  six  months.  It  is  commonly  not  attended 
with  dilatation  of  the  pupil.  It  is  sometimes  complete, 
but  more  frequently  partial.  Similar  weakness  of  accom- 
modation may  follow  epidemic  influenza,  "grip,"  and 
other  acute  diseases.  Paralysis  of  the  ciliary  muscle 
may  also  attend  degenerative  changes  in  the  brain  and 
spinal  cord. 

Spasm  of  the  ciliary  muscle,  or  spasm  of  accom- 
modation, has  been  already  alluded  to  (pages  129  and  149). 
It  also  is  produced  by  drugs,  eserin  (physostigmin)  and 
pilocarpin,  and  by  disease  of  the  central  nervous  system. 
The  treatment  is  the  use  of  a  mydriatic,  and  the  removal 
of  the  cause,  if  possible. 

SYMPATHETIC  OPHTHALMIA. 

When  after  the  injury  the  eye  remains  damaged  by 
plastic  inflammation  of  the  uveal  tract,  the  other  eye  is 
liable,  after  a  time,  to  suffer  from  what  is  called  sym- 
pathetic disease.  Somewhat  similar  cases  occur  where 
the  first  eye  is  diseased  without  traumatism  ;  but  these  may 
be  instances  of  bilateral  idiopathic  disease,  one  eye  being 
affected  before  the  other.  Sympathetic  involvement  of 
the  second  eye  has  been  recognized  for  two  hundred  years. 


334  SYMPATHETIC  OPHTHALMIA. 

Donders  pointed  out  that  there  were  two  separate  diseases, 
one  marked  by  great  liability  to  complete  destruction  of 
sight,  and  but  slightly  influenced  by  treatment,  sympathetic 
inflammation ;  the  other  causing  great  temporary  inter- 
ference with  vision,  but  promptly  cured  by  removal  of 
the  injured  eye,  sympathetic  irritation.  The  wounded  or 
first  aifected  eye  is  called  the  exciting  eye,  the  other  the 
sympathizing  eye. 

Sympathetic  Inflammation  (Sympathetic  Ophthal- 
mitis,  Cyclitis  or  Iridocyclitis,  Uveitis  Maligna,  Migratory 
Ophthalmia). — Sympathetic  ophthalmitis  is  a  general  in- 
flammation of  one  eye,  following  injury  to  the  other  eye, 
and  characterized  by  an  insidious  invasion,  severe  inflam- 
mation of  the  uveal  tract,  a  chronic  course,  with  strong 
tendency  to  repeated  relapses  and  exacerbations,  and  end- 
ing often  in  complete  blindness. 

Symptoms  and  Course. — Sympathetic  disease  rarely 
or  never  begins  until  two  or  three  weeks  after  the  injury 
of  the  exciting  eye.  It  most  frequently  occurs  at  from 
six  to  ten  weeks ;  and  after  two  years  from  the  primary 
injury  it  is  extremely  rare.  The  first  symptom  may  be 
inability  to  sustain  an  effort  of  accommodation  in  the 
sympathizing  eye.  This  is  usually  followed  by  hyperemia 
of  the  whole  eye,  at  first  slight,  but  gradually  increasing. 
In  a  few  cases,  there  has  been  early  optic  neuritis,  and 
neuroretinitis.  In  other  cases,  the  first  hyperemia  is 
mainly  conjunctival.  In  all  cases,  however,  there  soon 
appear  discoloration  of  the  iris,  pericorneal  redness,  pain, 
photophobia,  specks  of  exudate  on  the  posterior  surface 
of  the  cornea  (keratitis  punctata),  plastic  exudation  bind- 
ing the  iris  to  the  anterior  capsule ;  and  clouding  of  the 
vitreous  humor.  These  symptoms  increase  in  severity 
until  vision  is  greatly  impaired.  Under  treatment,  or 
possibly  without  it,  they  may  then  greatly  improve.  But 
usually  there  is. a  relapse,  the  plastic  exudation  increases, 
the  vitreous  becomes  more  clouded,  and  vision  still  further 
reduced. 

If  the  case  is  going  on  to  partial  or  complete  recovery, 
the  relapse  will  be  less  severe  than  the  original  attack ; 


SYMPATHETIC  OPHTHALMIA.  335 

and  probably  after  one  or  two  relapses  there  will  be  con- 
tinued improvement.  If  the  case  passes  toward  an  un- 
favorable termination,  each  relapse  leaves  the  eye  more 
damaged  ;  and  relapses  continue  to  occur  at  intervals  of  a 
few  weeks  to  many  months,  until  all  vision  is  lost,  and 
the  eyeball  shrunken  and  soft.  Commonly,  diminished 
tension  may  be  noticed  within  a  few  days  after  the  com- 
mencement of  the  inflammation  of  the  uveal  tract.  The 
pain  at  first  is  rather  slight,  and  the  iris  may  be  firmly 
bound  down  before  it  is  realized  that  the  inflammation  is 
at  all  serious.  Subsequently  the  pain  and  dread  of  use 
of  the  eyes,  or  of  exposure  to  light,  become  more 
marked. 

Opacity  of  the  vitreous  usually  interferes  with  the 
study  of  the  ophthalmoscopic  changes,  but  alterations  of 
the  choroid  are  the  rule,  while  much  inflammation  of  the 
optic  nerve  and  retina  are  believed  to  be  exceptional. 
Occasionally,  there  is  severe  inflammation  of  the  cornea 
and  conjunctiva,  the  latter  without  any  great  amount  of 
discharge.  Cases  have  been  reported  as  of  sympathetic 
origin,  where  the  inflammation  was  confined  to  the  cornea 
and  conjunctiva.  But  it  is  doubtful  if  these  should  be 
regarded  as  instances  of  sympathetic  disease. 

Causes  and  Pathology. — The  only  well  understood 
element  in  the  causation  of  this  disease  is  the  injury  to 
the  exciting  eye.  This  injury  may  possibly,  in  some 
cases,  be  a  simple  plastic  inflammation  of  the  uveal  tract 
of  that  eye.  But  in  the  great  majority  of  cases  it  is  a 
plastic  inflammation  following  perforation  of  the  coats, 
occasionally  following  perforation  by  ulceration,  as  in 
intra-ocular  tumor,  usually  following  perforation  by  trau- 
matism.  When  to  traumatism  is  added  the  lodgement 
of  a  foreign  body  inside  of  the  vitreous  chamber,  the  risk 
of  sympathetic  inflammation  is  greatly  increased.  The 
removal  of  such  a  foreign  body,  after  plastic  inflamma- 
tion has  been  set  up,  does  not  remove  all  chance  of 
sympathetic  disease,  but  does  diminish  the  probability  of 
its  occurrence.  Penetrating  wounds  of  the  ciliary  region 
have  been  noticed  to  be  especially  likely  to  cause  this 


336  CAUSES  AND  PATHOLOGY. 

disease.  Wounds  penetrating  through  the  cornea,  an- 
terior chamber  and  iris  are  decidedly  less  likely  to  cause 
it.  It  more  frequently  occurs  in  children  and  young 
persons  than  in  later  life. 

How  the  disease  of  the  exciting  eye  sets  up  the  disease 
in  the  other  is  not  known.  But  the  speculations  regard- 
ing it  are  of  interest  for  their  bearings  on  general 
pathology.  The  optic  nerves  connected  by  the  chiasm, 
and  the  lymph-channels  immediately  around  them,  have 
been  regarded  as  the  path  by  which  an  infection  "  mi- 
grated "  from  the  one  eye  to  the  other.  But  there  is  little 
microscopical  or  experimental  evidence  to  support  this. 
Experiments  made  to  confirm  it  have  nearly  all  failed  to 
produce  any  inflammation  of  the  second  eye.  And  where 
such  inflammation  was  produced,  it  was  probably  part  of  a 
general  infection  rather  than  a  genuine  sympathetic  oph- 
thalmitis.  It  has  been  supposed  that  the  ciliary  nerves 
were  the  channels  through  which  the  exciting  eye  in- 
juriously affected  the  sympathizing  eye ;  but  here  too, 
positive  evidence  is  lacking.  Sometimes  dhanges  have 
been  found  in  these  nerves,  sometimes  they  have  not; 
and  it  has  been  argued  that  if  these  nerves  do  constitute 
the  channels  of  morbid  action,  that  the  absence  of  marked 
lesions  is  what  should  be  expected,  because  their  influence 
must  be  that  of  perverted  function,  an  influence  which 
could  not  be  exerted  if  the  function  of  the  nerves  were 
wholly  destroyed. 

It  has  also  been  supposed  that  some  morbid  material 
entering  the  blood  from  the  exciting  eye  was  capable  of 
setting  up  inflammation  in  the  uveal  tract  of  the  other 
eye,  although  doing  no  harm  to  any  other  part  of  the 
body.  Finally  it  is  suggested  that  through  the  ciliary 
nerves  the  injured  eye  is  capable  of  unfavorably  influ- 
encing its  fellow,  so  that  the  influences  tending  to  excite 
inflammation  therein,  which  would  otherwise  be  success- 
fully resisted,  are  able  by  aid  of  this  morbid  predisposition 
to  overcome  the  resistance  of  the  tissues ;  and  that  a  sym- 
pathetic inflammation  is  set  up  by  the  injurious  substances 
from  the  exciting  eye,  or  the  ordinary  causes  of  inflam- 


SYMPATHETIC  OPHTHALMIA.  337 

mation  acting  in  the  presence  of  this  constant  unfavor- 
able influence  exerted  by  the  injured  eye. 

Diagnosis. — When  one  eye  has  been  lost  or  seriously 
impaired,  any  inflammation  in  the  second  eye  should 
excite  suspicion.  The  careful  examination  of  the  pre- 
viously blind  eye  will  then  indicate  if  it  be  liable  to  cause 
sympathetic  disease.  If  it  be  blind  with  diminished  ten- 
sion, adherent  and  degenerated  iris,  and  opacity  prevent- 
ing any  view  of  the  fundus,  especially  with  any  history 
of  injury,  it  must  be  regarded  with  grave  suspicion.  In 
the  supposed  sympathizing  eye  the  presence  of  the  signs 
of  iridocyclitis  point  to  sympathetic  inflammation.  With- 
out these  the  diagnosis  cannot  be  certainly  made. 

Even  though  the  disease  be  sympathetic,  one  must  still 
distinguish  between  inflammation  and  irritation.  Sympa- 
thetic inflammation  comes  on  usually  within  a  few  weeks  or 
a  few  months  after  injury.  Or  if  it  arises  later,  it  mostly 
follows  a  renewal  of  the  inflammation  in  the  exciting  eye. 
Irritation  usually  occurs  years  after  the  exciting  eye  has 
been  injured,  and  has  long  been  free  from  inflammation, 
and  its  tissues  have  undergone  degeneration,  especially 
if  it  be  the  seat  of  calcareous  changes,  or  ossification  of 
the  choroid. 

Sympathetic  irritation  may  be  attended  with  great 
irritability  of  the  sympathizing  eye,  increased  lacrima- 
tion,  fear  of  light  and  complete  inability  to  use  the  eye. 
But  on  examination  it  will  be  found  that  the  pupil  reacts 
freely  to  light,  and  that  the  iris  is  of  normal  appearance ; 
and  on  removal  of  the  cause  of  irritation,  complete  re- 
covery occurs  within  a  few  hours  or  days.  The  earliest 
symptoms  of  sympathetic  inflammation  may,  however, 
closely  resemble  those  of  sympathetic  irritation.  In  both 
cases  it  may  be  difficult  to  use  the  accommodation. 

Treatment. — The  fact  that  the  exciting  eye  has  already 
been  greatly  damaged  or  destroyed,  and  that  after  the 
actual  involvement  of  the  sympathizing  eye  the  most 
efficient  treatment  may  fail  to  save  it,  makes  prophylactic 
treatment  of  the  highest  importance..  This  consists  in 

22 


338  PROPHYLACTIC  TREATMENT. 

the  removal  of  what  is  liable  to  become  an  "  exciting 
eye."  On  this  account  the  eyeball  should  be  removed  : 
A.'  If  blind  from  injury  and  the  seat  of  iridoeyc/ifi*. 
(1).  When  known  or  supposed  to  contain  a  foreign  body 
which  cannot  be  extracted.  (2).  When  the  injury  has 
occurred  in  the  ciliary  region.  (3).  If  the  injury  be  recent 
(within  two  years)  and  the  patient  cannot  remain  within 
easy  reach  of  competent  professional  advice,  even  though 
the  eye  does  not  contain  a  foreign  body,  and  the  wound 
was  not  in  the  ciliary  region. 

B.  If  not  blind,  but  with  greatly  impaired  vision  and  the 
seat  of  iridocyclitis.     (1).  If  known  to  contain  a  foreign 
body  that  cannot  otherwise  be   removed.     (2).    If  the 
wound  be  in  the  ciliary  region,  and  the  inflammatory 
process  be  active  with  diminished  intra-ocular  tension. 

C.  If  the  eye  has  been  so  severely  injured  that  all 
chance  of  further  useful  vision  is  destroyed,  even  though 
inflammation  has  not  yet  set  in,  it  should  be  removed  if 
the  patient  cannot  remain  under  competent  observation. 

The  operations  of  enucleation  of  the  eyeball  and  its  sub- 
stitutes are  described  in  Chapter  XIX.  Their  value  in  pre- 
venting sympathetic  ophthalmitis  may  be  considered  here. 
It  cannot  be  claimed  that  evisceration,  with  or  without  the 
insertion  of  an  artificial  vitreous,  has  been  practiced  long 
enough  or  widely  enough  to  prove  that  it  is  equal  in 
value  to  enucleation ;  but  it  has  been  sufficiently  practised 
to  show  that  it  has  value  in  this  direction.  If  infection 
travelling  through  the  optic  nerve,  or  by  the  lymph-chan- 
nels adjoining  it,  be  a  factor  in  producing  sympathetic 
ophthalmitis,  evisceration  must  always  be  inferior  to 
enucleation  as  a  prophylactic  measure,  for  infection 
already  lodged  in  the  sclera  or  adjoining  Lymph-spaces 
would  be  undisturbed  by  evisceration,  but  would  be  thor- 
oughly .removed  by  enucleation.  Besides  the  removal  of 
the  injured  eye,  the  only  measures  of  prophylaxis  are 
those  of  general  hygiene,  and  care  iu  the  use  of  the  eyes. 

When  sympathetic  inflammation  has  already  begun,  we 
must  first  consider  the  value  of  the  exciting  eye.  In  a 
few  cases  this  retains  useful  vision ;  and,  singularly 


SYMPATHETIC  OPHTHALMIA.  339 

enough,  may  still  continue  with  useful  vision,  although 
the  sympathizing  eye  may  be  entirely  lost.  In  such  cases 
the  exciting  eye  will  be  in  the  end  the  only  seeing  eye 
and  must  therefore  be  retained.  But  if  the  sight  of  the 
exciting  eye  be  already  lost,  or  if  it  is  the  seat  of  active 
inflammation  that  is  likely  to  destroy  its  sight,  it  should 
be  removed  at  the  earliest  possible  moment.  Years  ago 
the  opposite  advice  of  a  few  authorities  left  the  surgeon 
in  uncertainty  as  to  what  he  should  do.  But  the  experi- 
ence of  the  profession  has  now  demonstrated  that  the 
chance  of  recovery  of  the  sympathizing  eye,  is  much 
better  if  the  exciting  eye  be  promptly  removed. 

The  adaptation  of  an  artificial  eye  to  replace  the  globe 
removed  is  discussed  in  Chapter  XIX. 

The  patient  should  be  confined  to  a  darkened  room, 
spending  must  of  the  time  in  bed,  but  allowed  to  move 
about  sufficiently  to  avoid  bed-weariness.  The  eye  must 
have  complete  rest  and  should  be  kept  fully  under  the 
influence  of  atropin,  unless  iritic  adhesions  have  already 
become  so  extensive  and  firm  that  the  drug  can  cause  but 
little  or  no  retraction  of  the  iris.  Leeches,  or  the  artifi- 
cial leech,  may  with  advantage  be  applied  to  the  temple 
daily  for  a  few  days  during  the  height  of  the  attack. 
Bathing  the  eye  for  a  few  minutes  in  very  hot  water 
may  be  practised  every  few  hours. 

The  general  treatment  should  include  the  use  of  mer- 
cury ;  up  to,  but  not  beyond,  the  point  of  constitutional 
impression.  This  may  be  given  in  laxative  doses  of 
calomel,  and  inunctions,  until  some  effect  is  produced ; 
and  then  its  action  sustained  by  the  internal  use  of  the 
protiodid  or  bichlorid.  In  addition,  tincture  of  the 
chlorid  of  iron  in  large  doses  has  appeared  beneficial ;  and 
small  doses  of  quinin  are  usually  indicated.  Equal  in 
importance  with  such  specific  medication  is  care  to  im- 
prove in  everv  way  the  general  health  and  nutrition  of 
the  patient.  If  pain  prevents  sleep,  small  doses  of 
morphin  or  acetanilid  may  be  given  each  evening. 

After  the  inflammation  has  subsided,  it  is  sometimes 
necessary  to  do  iridectomy  or  some  allied  operation,  to 


340  TREATMENT. 

make  a  clear  passage  where  the  pupil  has  been  closed  by 
the  attacks  of  inflammation.  Such  operations  are  diffi- 
cult on  account  of  the  inelastic  brittle  condition  of  the 
iris,  and  are  very  liable  to  be  followed  by  a  renewal  of 
inflammation.  They  are  best  postponed  until  many 
months,  or  even  years,  after  all  symptoms  of  inflammation 
have  subsided. 

Prognosis. — The  majority  of  cases  of  sympathetic 
ophthalmitis  end  in  blindness.  Probably  half  of  those 
energetically  and  intelligently  treated  from  early  in  the 
disease,  do  not  escape  this  fate ;  and  it  is  certain  in  all 
neglected  cases.  Even  when  the  disease  seems  to  yield 
promptly  to  treatment,  the  prognosis  must  be  carefully 
guarded.  The  special  tendency  to  relapse  must  be  in- 
sisted on  ;  and  where  the  eye  has  been  already  consider- 
ably damaged  the  danger  of  relapse  and  further  impair- 
ment will  not  be  over  for  two  years.  When,  however, 
the  relapses  become  less  and  less  severe,  and  the  eye  on 
the  whole  is  improving,  the  outlook  is  encouraging ;  and 
if  the  recovery  from  the  earlier  attack  is  complete,  and 
has  lasted  for  one  year,  the  eye  may  be  regarded  as 
cured. 

It  is  to  be  borne  in  mind  that  even  after  the  removal 
of  an  injured  eye  the  danger  of  sympathetic  inflamma- 
tion continues  for  at  least  three  or  four  weeks.  In 
numerous  cases  it  has  appeared  two  or  three  weeks  after 
the  removal  of  the  exciting  eye  ;  and  has  run  a  character- 
istic course,  though  generally  such  attacks  have  been  mild 
and  amenable  to  treatment. 

Sympathetic  Irritation  (Sympathetic  Neurosis). — 
This  condition,  long  confused  with  sympathetic  inflamma- 
tion, is  one  in  which  the  sympathizing  eye  may  be  ren- 
dered entirely  useless,  temporarily,  or  so  long  as  the 
exciting  eye  is  retained ;  yet  on  removal  of  the  exciting 
eye,  recovery  is  complete  within  a  few  hours  or  days. 

Symptoms  and  Course. — Sometimes  during  the  first 
few  days  after  injury  to  the  eye,  and  before  it  is  time  for 
sympathetic  inflammation  to  develop,  the  other  eye  may 
appear  disturbed,  very  sensitive  to  light  and  irritable 


SYMPATHETIC  OPHTHALMIA.  341 

when  used.  But  this  primary  disturbance  quickly  sub- 
sides and  many  months  or  years  elapse  before  true  sym- 
pathetic irritation  is  likely  to  be  developed.  It  begins 
with  difficulty  or  pain  in  using  the  eyes  for  near  work. 
If  the  accommodation  be  not  actually  diminished  in 
amount,  the  ciliary  muscle  is  quickly  tired  ;  and  blurring 
of  near-vision,  or  pain,  occurs  after  the  eyes  have  been  used 
but  a  short  time.  Soon  photophobia  and  excessive  lacrima- 
tion  develop;  then  general  hyperemia  of  the  conjunctiva  and 
sclera.  These  symptoms  may  yield  to  rest  of  the  eyes, 
or  may  improve  spontaneously.  But  in  the  course  of 
weeks  or  months  they  tend  to  recur,  grow  worse,  and  to 
be  more  constant.  The  patient  from  being  unable  to  do 
near  work  comes  to  find  it  difficult  to  make  his  way 
about,  and  may  become  as  helpless  as  though  the  sym- 
pathizing eye  were  the  seat  of  severe  inflammation.  The 
examination  of  the  eye  becomes  difficult,  but  the  pupil  is 
found  to  react  freely  to  light,  and  by  instilling  cocain,  it 
can  be  ascertained  that  the  fundus  and  media  of  the 
affected  eye  are  normal. 

The  diagnosis  has  been  discussed  in  connection  with 
that  of  sympathetic  inflammation. 

Treatment  and  Prognosis. — The  removal  of  the  ex- 
citing eye  is  the  only  treatment  and  the  whole  treatment. 
Perfect  cure  can  be  promised  from  it.  If  this  is  not 
removed,  the  disability  of  the  sympathizing  eye  will 
remain,  partial  or  complete,  under  any  other  treatment. 
For  the  relief  of  sympathetic  irritation  evisceration  is 
equally  as  effective  as  enucleation.  Even  optico-ciliary 
neurotomy  will  give  at  least  temporary  relief. 

DISEASES  OF  THE  CHORO1D. 

Purulent  Choroiditis  (Suppurative  Choroiditis  or 
Irido-choroidit'is,  Panophthalmitis).  —  Purulent  inflam- 
mation of  the  choroid  is  rarely  or  never  confined  to 
that  membrane.  Not  only  does  the  whole  uveal  tract 
participate  in  the  process,  but  the  retina  and  vitreous  are 
involved  and  usually  the  whole  eyeball,  and  sometimes 
adjoining  structures  suffer  with  it. 


342  PURULENT  CHOROIDITIS. 

Causes. — Direct  infections  by  perforating  wound  of 
the  eyeball,  septic  operations,  especially  cataract  extrac- 
tion or  needling,  or  suppurating  ulcer  of  the  cornea,  are 
the  common  causes  of  choroidal  suppuration.  It  may  also 
arise  from  suppuration  or  thrombosis  in  the  orbit.  From 
these  causes  it  attacks  only  the  one  eye.  It  also  occurs, 
generally  affecting  both  eyes,  from  metastasis  or  embolism, 
in  erysipelas,  puerperal  sepsis,  septic  endocarditis  and 
other  forms  of  pyemia,  scarlet  fever,  cerebrospinal  menin- 
gitis, influenza,  and  other  acute  specific  diseases. 

Symptoms  and  Course. — The  attack  is  usually  very 
severe.  The  exceptions  to  this  occur  late  in  the  course  of 
exhausting  febrile  disease,  and  with  cerebrospinal  menin- 
gitis in  young  children.  There  is  severe  pain  in  the  eye 
and  head,  intense  hyperemia  of  the  whole  eye  and  its  ap- 
pendages ;  swelling  of  the  conjunctiva  with  chemosis ; 
sudden  swelling  of  the  lids;  and  sometimes  such  swelling 
of  the  orbital  tissues  as  to  cause  marked  protrusion  of  the 
eyeball.  There  is  great  tenderness.  There  may  be  a  dis- 
tinct rigor ;  and  rapid  elevation  of  the  bodily  temperature, 
with  the  general  symptoms  of  pyrexia,  including 
delirium. 

The  vitreous  and  often  the  anterior  media  quickly 
become  so  hazy  that  nothing  can  be  seen  through  them, 
and  hypopyon  may  form.  In  most  cases  the  sclero- 
corneal  coat  is  perforated  so  as  to  permit  the  free  escape 
of  pus  before  any  marked  amelioration  of  symptoms 
occurs.  The  pain  then  diminishes,  the  eyeball  becomes 
soft,  shrinks,  and  phthisis  bulbi  results ;  the  eye,  after 
many  weeks,  or  even  months,  becoming  quiet,  and  free 
from  hyperemia  or  pain. 

Where  the  disease  arises  in  connection  with  the  specific 
fevers,  it  is  apt  to  run  a  less  violent  course.  Great  pain 
and  swelling  may  be  absent.  The  vitreous  becomes 
opaque,  and  appears  yellow  by  focal  illumination.  Hypo- 
pyon may  be  noticed  ;  but  there  occurs  no  perforation  of 
of  the  sclcro-corneal  coat.  The  tension  of  the  eyeball,  at 
first  rather  elevated,  falls  below  the  normal,  the  hyperemia 
and  tenderness  slowly  disappear,  and  after  many  weeks, 


DISEASES  OF  THE  CHOROID.  343 

the  eye  is  found  soft,  with  more  or  less  opacity  of  the 
vitreous,  and  discoloration  and  degeneration  of  the  iris. 
The  purulent  accumulation  in  the  vitreous  is  often  desig- 
nated pseud o-glioma.  Its  differentiation  from  glioma  of 
the  retina  is  important.  It  is  given  in  connection  with 
that  affection. 

In  a  few  cases,  usually  in  young  children,  after  cerebro- 
spinal  meningitis  (the  author  has  also  seen  it  after  typhoid 
fever),  some  sight  remains  in  the  eye,  and  slowly  improves 
with  the  diminution  of  the  vitreous  opacity,  which  con- 
tinues for  many  months,  or  even  years  afterward. 

Diagnosis. — Purulent  choroditis  is  only  liable  to  be 
overlooked  when  it  supervenes  upon  severe  inflammation 
of  the  eye,  as  suppuration  of  the  cornea  or  the  orbit,  or 
in  erysipelas  of  the  lids ;  or  when,  in  connection  with 
exhausting  general  disease,  the  onset  is  insidious  and  the 
patient  so  ill  as  not  to  call  attention  to  the  loss  of  sight. 
It  is  liable  to  be  mistaken  for  orbital  cellulitis,  in  which, 
however, the  dioptric  media  remain  clear;  or  confused  with 
acute  glaucoma,  which  can  be  known  by  the  dilated  pupil, 
the  absence  of  history  of  any  cause  for  choroidal  suppu- 
ration, and  the  lighter  swelling  of  the  conjunctiva  and 
neighboring  parts. 

Treatment. — This  is  to  be  directed  mostly  to  relieving 
pain  and  shortening  the  course  of  the  disease.  If  the 
patient  will  consent  to  it,  these  indications  will  be  most 
promptly  and  effectively  met  by  at  once  enucleating  the 
eyeball.  Enucleation  during  panophthalmitis  has  been 
credited  with  causing  meningitis  and  death.  Numerous 
cases  have  been  reported  in  which  death  by  meningitis 
followed  the  enucleation  of  suppurating  eyeballs.  But  in 
some  of  these  cases  it  is  evident  that  the  meningitis  had 
begun  before  the  enucleation,  and  in  others  it  is  probable 
that  it  would  have  occurred  without  enucleation,  as  it  has 
done  sometimes  when  enucleation  was  not  practiced.  The 
author  believes  that  the  patient's  risk  of  meningitis  is  not 
increased  by  enucleation  if  the  operation  is  a  surgically 
clean  one,  sufficient  bleeding  is  allowed,  and  perfectly  free 
drainage  of  the  orbital  tissues  is  secured.  The  former 


344  TREATMENT  OF  PANOPHTHALMITIS. 

practice  of  at  once  stopping  the  bleeding  that  follows 
enucleation,  by  packing  the  orbit,  and  keeping  it  for  hours 
under  firm  pressure,  was  far  more  likely  to  have  caused 
meningitis  than  the  enucleation. 

If  the  patient  refuses  enucleation,  or  his  general  con- 
dition prevents  it,  the  eye  may  be  poulticed ;  and  at  the 
end  of  two  or  three  days  freely  incised  through  the  cornea, 
to  allow  the  escape  of  the  crystalline  lens  and  the  puru- 
lent accumulations  behind  it.  Pain  may  be  lessened  by 
free  leeching  from  the  temple ;  and  opium  and  acetanilid 
given  internally.  A  free  laxative  may  be  given,  and 
afterwards  the  tincture  of  chlorid  of  iron,  and  quinin, 
with  such  other  treatment  as  the  patient's  general  con- 
dition demands. 

The  few  cases  in  which  any  vision  is  retained  should 
be  treated  without  poulticing  or  incisions,  commonly  with 
prolonged  rest  of  the  eyes  under  a  mydriatic.  Especial 
attention  should  be  given  to  everything  calculated  to  build 
up  the  general  health. 

Prognosis. — Severe  panophthalmitis  always  ends  in 
blindness,  generally  with  shrinking  of  the  eyeball.  But 
an  eye  thus  lost  is  not  likely  to  excite  sympathetic  inflam- 
mation. In  pseudo-glioma  there  is  no  chance  of  restoring 
sight.  In  the  few  cases  that  retain  some  vision,  slow 
improvement  may  continue  for  one  or  two  years,  and  very 
useful  although  not  perfect  sight  may  be  ultimately 
obtained. 

Plastic  Inflammation  and  Atrophy  of  the 
Choroid. — Under  this  head  are  included  all  non-puru- 
lent inflammations  of  the  choroid.  Although  to  some  of 
these  conditions  the  term  plastic  inflammation  may  appear 
not  to  be  strictly  applicable,  they  all  show  a  strong  ten- 
dency to  produce  permanent  visible  alterations  of  structure 
through  the  organization  of  exudates.  Such  alterations 
commonly  include  both  the  formation  of  cicatricial  con- 
nective tissue,  and  the  atrophy  to  a  greater  or  lesser  extent 
of  normal  choroidal  structures.  Hence  the  necessity  of 
considering  them  as  two  parts  of  a  single  process. 

Causes. — The  choroid  is  liable  to  be  involved  in  all 


DISEASES  OF  THE  CHOROID.  345 

kinds  of  inflammation  of  the  iris  and  ciliary  body,  so  that 
all  causes  for  those  inflammations  are  causes  of  choroiditis. 
Plastic  choroiditis  and  atrophy  also  arise  without  iritis  or 
cyclitis,  from  eye-strain,  especially  in  progressive  myopia  ; 
from  syphilis ;  from  obscure  disorders  of  general  nutrition 
attended  with  anemia,  in  connection  with  menstrual 
derangements ;  and  from  traumatism.  It  has  been  sup- 
posed that  choroidal  atrophy  occurred  without  inflamma- 
tion from  mere  stretching  of  the  choroid  in  high  myopia ; 
but  this  is  not  certain. 

Symptoms  and  Course. — The  characteristic  symptoms 
of  plastic  inflammation  of  the  choroid  can  only  be  studied 
with  the  ophthalmoscope.  The  acute  stages  attended  with 
hyperemia  may  present  flashes  of  light  that  occur  at  short 
intervals  when  the  patient  is  in  comparative  darkness. 
The  retina  in  contact  with  the  affected  area  may  suffer,  so 
as  to  cause  impaired  vision,  and  a  sense  of  a  cloud  before 
the  sight  (positive  scotoma).  But  if  the  affected  area  is 
away  from  the  macula,  this  impairment  of  vision  will 
readily  passed  unnoticed.  Accompanying  opacities  of  the 
vitreous  or  lens  may  also  impair  vision.  Sometimes  great 
atrophy  of  the  choroid  occurs  without  much  impairment 
of  vision  ;  and  the  choroidal  changes  may  be  far  advanced 
before  any  opacity  can  be  seen  in  the  vitreous  or  lens. 
The  process  may  be  entirely  painless,  or  there  may  be  a 
dull  aching  referred  to  the  eyes  and  frontal  region.  In 
the  absence  of  iritis  and  cyclitis,  the  eye  externally 
presents  a  normal  appearance ;  or  in  exceptional  cases 
there  is  a  slight  hyperemia  of  the  deep  scleral  vessels. 

With  the  ophthalmoscope  we  cannot  directly  recogni/e 
general  hyperemia  of  the  choroid  ;  but  it  is  attended  with 
heightened  color  of  the  optic  disk,  the  capillary  vessels 
of  which  spring  from  the  same  source  as  the  choroidal 
vessels,  and  not  from  the  central  retinal  vessels.  The 
early  stage  of  choroiditis  causes  a  lighter  yellowish  color 
of  the  fundus,  with  blurring  of  the  choroidal  details  if 
these  are  visible.  This  blurring  if  general  may  cause  a 
more  uniform  scarlet  color;  if  confined  to  certain  portions 
it  causes  blotches  of  the  lighter,  yellower  red.  A  slight 


346  SYMPTOMS  OF  CHOROJDITIS. 

choroidal  inflammation  is  apt  to  cause  absorption  of  the 
layer  of  pigment-cells  that  overlie  it,  the  retinal  pigment- 
layer.  If  this  layer  be  generally  absorbed,  the  choroidal 
vessels  are  visible,  as  in  Fig.  118,  and  the  upper  and 
lower  part  of  Fig.  110.  If  the  retinal  pigment-layer  be 
thinned  or  lacking  in  scattered  areas,  it  gives  the  fundus 
a  "  patchy  "  appearance. 

Acute  plastic  choroiditis  may  give  rise  to  well-marked 
localized  swellings  over  which  the  retinal  vessels  may  be 
seen  to  pass,  or  the  affected  area  may  be  partly  or  wholly 
hidden  by  a  diffuse  haziness  of  the  vitreous  in  front  of  it. 
After  a  few  days  or  a  few  weeks,  the  swelling  disappears 
and  the  choroid  in  the  affected  area  becomes  thinned. 
This  may  leave  the  larger  choroidal  vessels,  which  lie  in 
its  deeper  layer,  uncovered,  and  abnormally  prominent, 
or  it  may  include  these  so  that  the  affected  area  shows 
the  white  sclera. 

The  earliest  stages  of  choroiditis  show  no  pigment- 
changes,  but  as  the  case  progresses  toward  atrophy  these 
always  occur.  The  margin  of  the  affected  area  always 
shows  specks  and  blotches  of  dark-brown  or  black  pig- 
ment-masses ;  and  similar  deposits  occur  within  the  atro- 
phic  area.  Such  deposits  may  be  noticeable  within  two 
weeks  of  the  onset  of  acute  choroiditis ;  but  they  may 
continue  to  increase  and  alter  for  many  months.  Finally 
they  seem  to  reach  a  permanent  condition,  and  remain 
with  atrophy  throughout  life,  a  visible  record  of  previous 
disease.  Their  appearance  is  illustrated  in  Fig.  110. 
Opacities  in  the  vitreous  and  crystalline  lens  may  also 
remain  as  evidence  of  a  previous  choroiditis. 

Varieties. — Myopic  choroiditis  has  already  been  de- 
scribed in  connection  with  myopia  (page  160).  Dissemi- 
nated choroiditis  is  characterized  by  distribution  of  the 
choroidal  changes  in  scattered  areas,  the  intermediate 
fundus  being  comparatively  normal  as  in  Fig.  110. 
One  or  two  such  areas,  the  remainder  of  the  choroid 
being  healthy,  constitute  a  localized  choroiditis.  A 
single  area  occurring  at  the  macula  is  called  a  central 
choroiditis.  In  this  position  the  scotoma  it  causes  is  sure 


DISEASES  OF  THE  CHOROID. 


347 


to  attract  attention;  and  even  comparatively  slight 
changes  will  be  noticed  on  that  account.  A  form  of 
central  clioroiditis  occurring  in  old  people,  called  there- 
fore senile  choroiditis,  may  be  a  cause  of  poor  vision  and 
disappointment  after  cataract  extraction.  In  anterior 
choroiditis  the  lesions  are  confined  to  the  anterior  portion 


Fio.  110. — Disseminated  clioroiditis.  Patches  of  choroidal  atrophy  scattered 
over  the  fundus.  The  macula  has  escaped  damage.  A  partial  atrophy  near 
the  left  upper  corner  exposes  the  choroidal  vessels. 

of  the  choroid.  Sometimes  they  are  so  far  forward  as  to 
be  out  of  sight  with  the  ophthalmoscope ;  and  their  ex- 
istence can  only  be  guessed  from  the  presence  of  opacities 
in  the  anterior  portion  of  the  vitreous. 

Diffuse  choroiditis  invades  one  or  a  few  large  areas  of 
the  fundus.  The  exudate  is  usually  extensive,  and  slowly 
gives  place  to  atrophy.  Marked  pigment-changes  may 
be  noted  while  yet  the  yellowish  color  of  the  exudute 
forms  the  background  for  the  pigment-markings. 

Diagnosis. — Choroidal  inflammation  and  atrophy  must 


348  DIAGNOSIS  OF  CHOROIDITIS. 

be  distinguished  from  retinitis,  by  the  fact  that  the  retinal 
vessels  are  not  altered  in  size  or  outline,  and  are  not  hid- 
den or  partially  obscured  in  certain  parts  of  their  course. 
This  will  also  distinguish  choroidal  atrophy  from  other 
retinal  conditions  as  opaque  nerve-sheaths,  fatty  degene- 
ration, etc.  It  must,  however,  be  remembered  in  con- 
nection with  choroiditis  that  diffuse  haziness  of  the 
vitreous  may  so  veil  the  retinal  vessels  as  to  simulate 
retinitis ;  and  that  not  rarely  both  retina  and  choroid  are 
involved  in  the  same  inflammation  (see  page  101).  Atrophy 
of  the  choroid  must  also  be  distinguished  from  coloboma. 
This  is  most  difficult  as  between  the  rounded  partial 
colobomas  that  occur  in  the  macula  and  elsewhere,  and 
isolated  patches  of  choroidal  atrophy.  The  black  pig- 
ment-deposits in  the  choroid  may  be  confused  with  opa- 
cities in  the  vitreous  or  lens.  Compare  Figs.  63  and  110 
with  Figs.  115, 116, 117,  and  118.  Patches  of  anomalous 
pigmentation  may  readily  be  taken  for  patches  of  choroid- 
itis. (See  page  99.) 

Treatment. — For  choroiditis  the  eyes  should,  as  far  as 
possible,  be  put  at  rest,  usually  under  the  full  influence 
of  a  mydriatic.  They  should  constantly  wear  correcting 
glasses.  In  acute  cases  the  patient  may  be  kept  for  a  few 
days  in  a  darkened  room,  with  little  active  exertion ;  and 
local  bleeding  from  the  temple  may  be  practiced  on  suc- 
cessive days.  Exposure  to  excessive  light  and  sudden 
changes  of  light  must  be  avoided,  dark  glasses  which  are 
large  enough,  and  fit  so  as  to  protect  the  eyes  thoroughly, 
should  be  worn  out  of  doors.  The  eyes  must  also  be 
guarded  from  radiant  heat  as  from  a  stove,  open  fire,  or 
lighted  lamp. 

Alteratives,  especially  mercury  and  potassium  iodid  are 
commonly  given  for  a  considerable  time.  If  syphilis  is 
probable,  the  former  should  be  used  freely  by  inunction, 
until  its  constitutional  effects  begin  to  manifest  them- 
selves. Subconjunctival  injections  of  mercuric  chlorid 
have  been  advocated  as  of  marked  value.  Any  other 
probable  cause  or  underlying  dyscrasia  should  receive 
appropriate  treatment.  But  often  none  can  be  discovered. 


DISEASES  OF  THE  CHOROID.  349 

It  is  then  of  the  highest  importance  in  all  cases  to  im- 
prove the  general  condition  of  the  patient.  On  this 
account  confinement  to  a  dark  room  should  be  resorted  to 
only  in  the  acute  cases,  and  with  them  limited  to  a  very 
few  days.  In  chronic  cases,  the  patient  should  live  as 
much  as  possible  in  the  open  air,  and  often  a  change  of 
occupation  or  residence  will  be  of  benefit. 

Prognosis. — Choroiditis  is  always  a  very  serious  dis- 
ease. Sight  lost  through  it  is  never  perfectly  restored ; 
and  so  long  as  it  is  active,  or  recurs  involving  new  areas, 
every  effort  should  be  made  to  limit  its  ravages.  Local- 
ized choroiditis  due  to  eye-strain  is  most  amenable  to 
treatment ;  and  next  to  this,  choroiditis  due  to  syphilis ; 
these  being  the  varieties  whose  etiology  is  best  under- 
stood. 

Choroidal  hemorrhage  is  rare  as  compared  with 
retinal  hemorrhage.  If  deep  and  diffused,  it  may  merely 
cause  a  deeper  red  of  the  affected  portion  of  the  fundus ; 
if  more  superficial,  it  cannot  be  distinguished  from  hemor- 
rhage in  the  deep  layers  of  the  retina,  except  that  it 
has  not  the  very  dark  red  color  sometimes  presented  by 
retinal  hemorrhage.  From  hemorrhage  into  the  nerve- 
fiber  layer  of  the  retina,  it  is  distinguished  by  its  rounded 
outlines  as  contrasted  with  the  "  flame  shape "  of  the 
retinal  hemorrhage.  The  choroidal  vessels  are  the  most 
frequent  source  of  hemorrhage  into  the  vitreous.  The 
treatment  is  merely  that  of  the  associated  conditions. 

Detachment  of  the  choroid  from  the  sclera  is 
sometimes  found  in  dissecting  degenerated  eyeballs,  but 
is  very  rarely  seen  with  the  ophthalmoscope.  So  seen,  it 
cannot  be  distinguished  from  detachment  of  the  retina, 
unless  the  choroidal  vessels  are  visible,  in  which  case  it 
resembles  sarcoma  of  the  choroid. 

Colloid  masses  may  form  in  the  choroid  in  elderly 
people,  causing  rounded  whitish  spots,  which  may  be 
massed  together  at  the  macula,  or  scattered  over  the 
fundus.  They  do  not  necessarily  impair  vision. 

Ossification  of  the  Choroid. — In  eyes  long  blind 
and  degenerated,  calcareous  change  is  often  found  in  the 


350  OSSIFICATION  OF  THE  CHOROID. 

choroid ;  and  sometimes  the  choroid  is  replaced  by  true 
osseous  tissue.  If  the  ossification  be  sufficiently  extensive, 
it  may  be  detected  by  pressure  upon  the  globe  through 
the  closed  lids.  It  may  become  an  indication  for  removal 
of  the  eye,  by  causing  sympathetic  irritation. 

Shrinking  of  the  eyeball  is  apt  to  follow  extensive 
plastic  disease  of  the  uveal  tract.  With  the  contraction 
and  organization  of  the  exudate,  which  forms  a  mass  be- 
hind the  lens,  the  retina  is  detached  from  the  choroid, 
and  drawn  with  the  shrunken  vitreous  into  a  chord, 
stretching  from  the  optic  nerve  to  the  posterior  pole  of 
the  lens.  The  lens  is  often  shrunken  and  pushed  forward, 
the  anterior  chamber  appears  shallow,  and  the  cornea 
smaller  than  normal.  The  eyeball  is  softened,  so  that  the 
pressure  of  the  four  recti  muscles  causes  it  to  assume  a 
somewhat  quadrate  form.  This  condition  comes  on 
slowly,  sometimes  after  repeated  attacks  of  inflammation, 
sometimes  after  a  single  severe  attack.  When  suppura- 
tion of  the  uveal  tract  goes  on  to  perforation  of  the  sclero- 
corneal  coat  the  shrinking  is  more  irregular,  much  more 
rapid,  and  the  resulting  stump  smaller,  with  less  resem- 
blance to  a  normal  eye.  Fuchs  calls  the  former  condition 
atrophy  of  the  eyeball,  the  latter  phthisis  bulbi.  Other 
writers  use  these  terms  interchangeably.  The  former 
condition  is  attended  with  greater  danger  of  sympathetic 
inflammation,  and  therefore  is  an  indication  for  enuclea- 
tion.  The  latter  may  permit  of  the  wearing  of  an  arti- 
ficial eye  over  the  stump.  Either,  after  many  years,  may 
cause  sympathetic  irritation. 


TUMORS  OF  THE  CHOROID. 

Sarcoma  of  the  choroid  occurs  about  once  in  3000 
cases  of  eye-disease,  mostly  about  middle  age.  It  starts 
usually  as  a  rounded  lobulated  tumor  in  the  fiindus  of  the 
eye,  distinguished  from  detachment  of  the  retina  by  the 
vessels  which  may  be  seen  lying  beneath  the  retina.  Its 
appearance  is  illustrated  in  Fig.  111. 

The  growth  causes  blindness  of  the  overlying  retina, 


DISEASES  OF  THE  CHOROID.  351 

and  a  corresponding  defect  in  the  field  of  vision.  But  if 
it  does  not  involve  the  region  of  the  macula,  it  may  grow 
a  long  time  without  attracting  the  patient's  attention,  and 
without  any  alteration  of  the  external  appearance  of  the 
eye,  or  other  symptoms.  Hence  this  is  called  the  latent 
stage  of  the  disease.  It  often  lasts  for  years. 

Later  the  eye  begins  to  show  evidences  of  deep  inflam- 
mation, and  the  tension  of  the  globe  is  increased.  This 
is  called  the  inflammatory  or  glaucomatous  stage.  The  an- 


FIG.  111.— Sarcoma  of  the  choroid  in  the  right  eye,  starting  to  the  temporal 
side  of  the  macula;  first  stage.  The  rounded  masses  of  the  growth  are  seen  on 
the  left,  containing  vessels  that  look  like  choroidal  vessels,  and  with  the  finer 
retinal  vessels  running  over  them. 

terior  chamber  is  shallow,  the  eye  painful ;  and  it  may  be 
very  difficult  to  make  the  diagnosis  between  this  condi- 
tion and  ordinary  glaucoma.  After  a  time,  varying  from 
a  few  weeks  to  many  months,  the  growth  penetrates  the 
sclera,  the  tension  of  the  eyeball  falls,  and  the  pain 
abates.  If  the  perforation  be  far  enough  forward,  the 
tumor-mass  is  at  once  seen  springing  from  it,  but  if  out 


352  SARCOMA   OF  THE  CHOROID. 

of  sight,  the  case  may  still  remain  obscure.  In  this  third 
stage  its  growth  is  rapid  and  soon  causes  the  appearance 
of  a  large  tumor  in  the  orbit.  The  fourth  or  final  stage 
begins  with  the  involvement  of  other  portions  of  the 
body  by  metastasis.  The  case  ends  in  death  from  rapid 
exhaustion  or  the  overwhelming  of  some  vital  organ. 

Diagnosis. — Sarcoma  of  the  choroid  is  distinguished 
from  glioma  of  the  retina  by  the  age  of  the  patient. 
Sarcoma  is  extremely  rare  in  childhold ;  glioma  occurs 
only  before  the  age  of  twelve  years.  From  simple  de- 
tachment of  the  retina,  it  is  known  by  the  reddish -yellow 
color,  the  appearance  of  vessels  beneath  the  retina,  and 
the  absence  of  the  wavy  motion  of  the  detached  retina 
floating  on  serous  fluid.  In  some  cases,  however,  the 
choroidal  tumor  is  masked  by  detachment  of  the  retina 
upon  a  serous  effusion.  Ophthalmoscopic  examination, 
using  direct  sunlight,  may  reveal  the  tumor  through  the 
detached  retina.  The  distinction  from  primary  glaucoma 
is  given  in  connection  with  that  disease  (Chapter  XV). 
When  the  tumor  has  perforated  the  sclera,  its  character 
may  be  recognized  by  the  microscope ;  or,  usually,  by  its 
abundant  pigmentation. 

Treatment. — This  is  the  earliest  possible  removal  of 
the  eyeball ;  or  if  the  sclera  is  already  perforated,  the 
removal  of  the  whole  contents  of  the  orbit.  When  the 
growth  cannot  wholly  be  removed,  the  treatment  with 
the  mixed  toxins  of  erysipelas  and  bacillus  prodigiosis 
(Coley's  method)  offers  a  small  chance  of  cure.  If  the 
growth  of  the  tumor  cannot  be  checked,  it  should  be  kept 
well  cleansed  and  disinfected. 

Prognosis. — The  spindle-cell  variety  of  sarcoma  may 
be  permanently  cured  by  complete  removal.  Round-cell 
sarcoma  returns ;  often  very  promptly,  sometimes  not  for 
several  years.  The  life  of  the  patient  may  not  be 
materially  prolonged  by  the  removal  of  a  round-cell 
sarcoma ;  but  the  course  of  the  disease  may  often  be  ren- 
dered less  painful,  and  a  respite  secured,  even  though  the 
recurring  growth  may  seem  to  progress  more  rapidly. 

Tuberculosis  of  the   choroid  is  rare.     It  causes 


DISEASES  OF  THE  CHOROID.  353 

rounded  yellowish  spots,  which  grow  rapidly  without  pig- 
ment-changes, but  rarely  reach  the  size  of  the  optic  disk. 
These  require  no  treatment.  Sometimes  it  forms  a  single 
large  mass  resembling  sarcoma,  for  which  the  eye  should 
be  enucleated. 

Carcinoma  and  adenoma  occur,  the  former  as  a 
rare  tumor  usually  secondary  to  carcinoma  of  the  breast. 

ANOMALIES  OF  THE  IRIS  AND  CHOROID. 

Anomalies  of  the  Iris. — The  iris  is  never  of  uni- 
form color  throughout,  nor  are  the  markings  precisely 
alike  in  the  two  eyes.  When  the  differences  of  color  are 
very  striking  the  condition  is  termed  heterochromia.  The 
small  dark  masses  at  the  edges  of  the  pupil,  called  ectro- 
pion  of  the  uvea  have  been  already  alluded  to  (see  page 
331). 

The  fibrovascular  membrane  which  occupies  the  pupil 
in  early  fetal  life,  is  sometimes  incompletely  removed, 
leaving  one  or  more  threads  of  opaque  tissue  which  ex- 
tend into  or  across  the  pupil,  called  persistent  pupillary 
membrane.  Such  threads  are  distinguished  from  posterior 
synechias  due  to  iritis  by  the  fact  that  they  are  attached 
not  to  the  pupillary  margin  of  the  iris,  but  distinctly  to 
its  anterior  surface.  If  numerous,  they  may  connect  with 
a  mass  lying  in  the  pupil,  and  attached  to  the  anterior 


FIG.  112.— Persistent  pupillary  mem-          FIG.  113. — Polycoria   seen  by  oph- 
brane,  usually  gray  or  the  color  of       thalmoscopic  illumination, 
the  iris. 

surface  of  the  lens.     The  more  common  appearance  is 
shown  in  Fig.  112. 

Anomalies  of  the  Pupil. — Displacement  of  the 
pupil  from  its  position  near  the  center  of  the  iris  is  called 
corectopia.  Multiple  pupil  is  called  polycoria.  Only 

23 


354  ANOMALIES  OF  THE  PUPIL. 

one  of  such  pupils  is  supplied  with  a  distinct  sphincter, 
except  in  the  case  where  the  normal  pupil  is  divided  into 
two  by  a  persistent  pupillary  membrane.  Sometimes  the 
pupil  is  extended  in  a  certain  direction,  usually  down- 
ward, by  a  deficiency  of  the  iris-substance.  This  is  called 
coloboma  of  the  iris.  The  anomaly  may  amount  to  only 
a  slight  notch  in  the  margin  of  the  iris,  may  extend  partly 
across  the  iris,  or  may  include  its  whole  width,  the  pupil 
reaching  behind  the  margin  of  the  cornea.  It  may  vary 
in  width  and  shape.  A  common  form  is  shown  in  Fig. 


FIG.  114.— Congenital  coloboma  of  the  iris,  pupil  extending  downward,  below 
the  lower  margin  of  the  cornea. 

114,  as  seen  by  oblique  illumination.  It  may  accompany 
coloboma  of  the  lens  as  shown  in  Fig.  133,  which  re- 
presents its  appearance  as  seen  with  the  ophthalmoscope. 
Its  form  is  more  rounded  than  that  of  the  coloboma 
usually  left  by  iridectomy  (see  Fig.  165).  In  rare  cases 
the  pupil  extends  the  whole  width  of  the  cornea,  no  iris 
being  visible.  This  is  called  aniridia  or  irideremia. 
With  the  ophthalmoscope  a  dark  line  shows  the  margin 
of  the  lens  against  the  general  red  ground  of  the  fundus- 
reflex. 

Coloboma  of  the  choroid  occurs  in  two  forms.  In 
one  the  deficiency  of  the  choroid,  allowing  the  white  sclera 
to  be  seen  through  it,  extends  backward  from  the  ciliary 
region  (usually  from  below)  toward  the  optic  disk,  some- 
times not  extending  to  it,  sometimes  including  it.  This 
form  is  frequently  accompanied  by  coloboma  of  the  iris 
and  lens.  It  is  illustrated  in  Fig.  115.  The  other  form 
consists  of  a  rounded  area,  sometimes  situated  at  the 
macula,  sometimes  in  other  parts  of  the  fundus.  The 
coloboma  is  often  crossed  by  retinal  vessels,  sometimes 


ANOMALIES  OF  THE  CHOROID. 


355 


also  by  large  choroidal  vessels.  Its  margins  always  show 
pigment-masses,  and  some  pigmentation  may  be  scattered 
over  its  surface.  It  may  be  divided,  as  in  Fig.  115,  by  a 


FIG.  115.— Coloboma  of  the  ehoroid  of  the  left  eye.  Below  the  optic  disk  is 
seen  a  small  oval  coloboma,  and  below  it  a  larger  one  that  stretches  forward 
probably  to  the  ciliary  body.  Retinal  vessels  cross  it,  and  a  choroidal  vessel 
runs  out  into  it. 

narrow  strip  of  normal  or  nearly  normal  fundus.  It  may 
be  of  about  the  same  level  as  the  adjoining  fundus,  or 
considerably  depressed  in  portions  or  throughout.  It  is 
distinguished  from  choroidal  atrophy,  albuminuric  retin- 
itis,  and  opaque  nerve-fibres,  chiefly  by  its  regular  rounded 
form,  and  from  the  last  two  by  the  pigmentation  of  its 
margin  (compare  Fig.  115,  with  Figs.  110,  117,  and  125). 
Albinism. — The  absence  of  pigment  from  the  uveal 
tract  accompanies  the  yellowish-white  hair,  eyebrowrs  and 
lashes,  and  the  absence  of  pigment  in  the  skin,  that  char- 
acterize the  albino.  The  iris  usually  appears  a  dull 
leaden-blue  or  gray,  the  pupil  may  show  a  red  reflex  even 
by  ordinary  illumination.  With  the  ophthalmoscope  the 


356  ALBINISM. 

pink  fundus-reflex  may  be  obtained  through  the  iris. 
The  whole  fundus  appears  yellowish-white,  with  the  optic 
disk  very  pink  by  contrast.  The  choroidal  and  retinal 
vessels  are  seen  with  equal  distinctness,  and  apparently 
intermingled.  The  condition  is  liable  to  be  hereditary 
or  to  affect  brothers  and  sisters.  It  is  in  most  cases 
attended  with  very  marked  errors  of  refraction,  especially 
high  astigmatism  and  hyperopia.  The  eyes  are  habit- 
ually partly  closed,  to  lessen  the  amount  of  light  entering 
them,  and  to  diminish  the  effects  of  imperfect  focussing. 
Such  eyes  require  the  careful  correction  of  refractive 
errors,  and  guarding  from  sudden  changes  of  illumina- 
tion. 

Minor  Anomalies  of  Pigmentation. — The  choroid 
presents  all  grades  of  pigmentation,  from  complete  absence 
in  the  albino,  to  the  dark  saturation  which  gives  the  negro 
fundus  a  dark  brown,  rather  than  red  appearance.  Oc- 
casionally isolated  black  or  brown  points  or  patches  of 
pigment  are  seen  as  congenital  anomalies,  often  but  a 
single  one,  sometimes  several  scattered  through  the 
fundus.  Sometimes  one  or  more  large  irregular  patches 
of  the  sort,  resembling  the  common  representations  of 
sun-spots,  may  be  found  in  the  macula.  Such  anomalous 
pigment-deposits  are  distinguished  from  those  of  atrophy 
by  the  absence  of  thinning  or  other  defect  of  the  choroid. 
They  cause  no  impairment  of  vision. 

BIBLIOGRAPHY. 

Diseases  of  the  Iris  and  Ciliary  Body.  W.  A.  Brailey  and  Sydney 
Stephenson,  "System  of  Diseases  of  the  Eye,"  vol.  iii. 

Inflammation  of  the  Uveal  Tissue  of  the  Iris.  Grandclement, 
"Ophthalmic  Keview,"  Dec.,  1896. 

Serous  Cyclitis.  N.  C.  Ridley,  "Roy.  London  Ophthalmic  Hosp. 
Rep.,"  vol.  xiv,  pt.  i. 

Gouty  and  Rheumatic  Affections  of  the  Uveal  Tract.  R.  Sattler, 
"  Trans.  Congress  of  Amer.  Phys.  and  Surg.,"  1897. 

Tubercle  of  the  Iris.  J.  A.  Andrews,  "  Trans.  Amer.  Ophthalmol. 
Soc.,"  1896. 

Cyst  of  the  Ciliary  Body.  M.  W.  Zimmerman,  "  Annals  of  Oph- 
thalmol.," July,  1897. 

Adenoma  of  the  Ciliary  Processes.  A.  Alt,  "Amer.  Jour,  of  Oph- 
thalmol.," Dec.,  1898. 


DISEASES  OF  THE   UVEAL   TRACT.  357 

Anatomy  and  Pathology  of  the  Eye.     E.  T.  Collins.    H.  K.  Lewis, 

London. 
Recurring  Internal  Ophthalmoplegia.     H.  F.  Hansell,  "  Ophthalmic 

Record,"  April,  1898. 
Sympathetic   Ophthalmia.     C.  E.  Shaw,  "Brit.  Med.  Jour.,"  June 

18,  1898;  O.  Sclurmer,  "Ophthal.  Review,"  Mar.,  1893;  R.  L. 

Randolph,  "  System  of  Dis.  of  the  Eye,"  vol.  iii. 
Operations  on  Eyes  Blinded  by  Sympathetic  Ophthalmitis.     J.  B. 

Story,  "  Ophthalmic  Review,"  Mar.,  1891. 
Metastatic   Choroiditis   Following   Puerperal    Septicemia.       J.   H. 

Claiborne,  "  Annals  of  Ophthalmol.,"  April,  1897. 
Meningitis  Following  Excision  of  the  Eyeball  for  Panophthalmitis. 

C.   D.   Marshall,    "Roy.  Lond.    Oph.   Hosp.  Rep.,"  vol.  xiv, 

pt.  ii. 

Mules'    Operation   vs.    Evisceration.     F.  Buller,   "Ophthalmic  Re- 
view," Sept.,  1897. 
Evisceration  of  the  Eye.    F.  C.  Hotz,  "  Trans.  Sect,  on  Ophthalmol., 

Amer.  Med.  Assoc.,"  1893. 
Diseases  of  the  Choroid  and  Vitreous.    A.  Hill  Griffith,  "System 

of  Diseases  of  the  Eye,"  vol.  iii. 
Extensive  Colloid  Changes  in  the  Choroid.     J.  T.  Carpenter,  "Trans. 

Sect,  on  Ophthal.  Amer.  Med.  Assoc.,"  1895. 

Metastatic  Carcinoma  of  the  Eyeball.     C.  D.  Marshall,  "Roy.  Lon- 
don Ophthal.  Hosp.  Rep.,' '  vol.  xiv,  pt.  iii. 
Primary  Sarcoma  of  the  Iris.     C.  A.  Veasey,  "Trans.  Sect,  on  Oph., 

Amer.   Med.   Assoc.,"    1897;  "Ann.   of  Ophthal./'  Oct.,  1897. 
Sarcoma  of  the  Uveal  Tract.   J.  B.  Lawford  and  E.  T.  Collins.    "  Roy. 

London  Ophthal.  Hosp.  Rep.,"  vol.  xiii,  pt.  ii.    C.  D.  Marshall, 

vol.  xv,  pt.  i. 

Intra-ocular  Growths.     W.  A.  Holden,  "  American  Text-book." 
Pernicious   Influence  of  Albinism  upon   the   Eye.     G.   M.  Gould, 

"  Trans.  Sect,  on  Oph.,  Amer.  Med.  Assoc.,"  1893. 


CHAPTER   XII. 

DISEASES  OF  THE  KETINA. 

THE  diagnosis  of  diseases  of  the  retina  is  to  be  made 
with  the  ophthalmoscope.  Most  of  them  are  classified  as 
forms  of  retinitis.  Their  treatment  includes  both  local  and 
general  measures,  the  latter  being  often  the  more  im- 
portant. 

Symptoms  of  Retinal  Disease. — Impairment  of 


358  SYMPTOMS  OF  RETINAL  DISEASE. 

Vision. — Retinal  disease,  not  manifest  in  any  other  way, 
will  cause  impairment  of  vision.  It  may  manifest  itself 
by  abnormal  after-images,  or  deficient  power  of  recovery 
from  the  changes  produced  by  exposure  to  light,  which 
may  lead  to  impairment  of  vision  in  strong  light,  day- 
blindness;  or  its  undue  impairment  in  diminished  light, 
niyht-blindness.  The  latter  is  apt  to  occur  endemic-ally 
when  nutrition  is  impaired,  especially  by  lack  of  food,  or 
confinement.  The  retina,  otherwise  normal,  may  so  suffer 
from  prolonged  exposure  to  excessive  light  as  to  have 
its  sensitiveness  greatly  impaired,  even  for  comparatively 
strong  illumination,  snow-blindness.  This  occurs  from 
exposure  in  high  mountains  and  in  polar  regions.  It  is 
distinct  from  retinitis  due  to  excessive  light  (see  page  371). 

Hyperesthesia  of  the  retina  shows  itself  by  discom- 
fort in  the  presence  of  strong  light,  and  attempts  to  avoid 
it ;  but  without  the  tendency  to  close  the  lids,  and  press 
upon  them,  which  is  shown  in  the  photophobia  of  con- 
junctivitis or  keratitis. 

Metamorphopsia,  due  to  displacement  of  the  percipient 
elements  of  the  retina  by  exudation,  is  usually  noticed 
when  retinitis  involves  the  region  of  the  macula.  Fine 
parallel  lines,  when  their  images  fall  on  the  affected  area, 
appear  crowded  together  from  separation  of  the  retinal 
elements,  or  spread  apart  by  crowding  together  of  these 
elements ;  or  a  straight  line  appears  to  have  an  angle  at 
the  point  looked  at ;  or  one  portion  of  the  line  appears 
displaced  as  regards  the  other  portion.  These  appear- 
ances are  most  noticeable  when  the  line  is  turned  in  some 
special  direction. 

Hyperemia  of  the  retina  is  recognized  chiefly  in  the 
enlargement  of  the  larger  retinal  vessels.  These  vary 
markedly  in  caliber  in  normal  eyes,  so  that  only  extreme 
departures  from  the  usual  standard  can  be  classified  as 
abnormal,  unless  the  eye  in  question  has  been  recently 
examined  ophthalmoscopically.  Tortuosity  of  the  ves- 
sels is  a  more  definite  evidence  of  increase  in  their  full- 
ness ;  but  even  very  marked  tortuosity  may  occur  as  a 
congenital  anomaly  in  perfectly  healthy  eyes,  and  may  be 


DISEASES  OF  THE  RETINA.  359 

limited  to  a  single  retinal  vessel  (see  also  page  9 2).  Undue 
redness  of  the  optic  disk  is  apt  to  occur  with  retinal  hy- 
peremia. 

Anemia  of  the  retina  of  a  moderate  degree  is  even 
harder  to  recognize  with  certainty  than  is  hyperemia.  It 
is  shown  by  narrowing  of  the  vessels,  and  straightening 
of  their  course.  Acute  anemia  of  the  retina  with  ex- 
treme contraction  of  the  retinal  arteries,  the  veins  being 
broad  and  dark  with  pallor  of  the  optic  disk,  and  sud- 
den blindness  is  called  ischemia  of  the  retina.  It  occurs 
after  excessive  hemorrhage,  as  metrorrhagia,  and  in  acute 
disease,  as  erysipelas,  and  cholera.  In  quinin-blindness 
both  arteries  and  veins  are  contracted.  Both  hyper- 
emia and  anemia  of  the  retina  are  frequently  judged 
present  or  absent  merely  by  the  hyperemia  or  anemia  of 
the  optic  disk  ;  but  it  must  be  remembered  that  the  cir- 
culation of  the  optic  disk  is  even  more  intimately  con- 
nected with  the  circulation  of  the  choroid  than  with  that 
of  the  retina. 

Alterations  of  the  Vessels. — General  anemia  shows 
itself  in  the  retina  by  quite  other  signs  than  those  of 
retinal  anemia.  The  retinal  veins  become  broad  and  pale 
with  a  wide  light  streak.  Changes  in  the  blood,  as  in 
diabetes,  may  alter  the  color  of  the  retinal  vessels  so  that  it 
becomes  difficult  to  distinguish  arteries  from  veins  or 
either  from  the  general  color  of  the  fundus.  Patches  of 
fatty  degeneration  causing  a  glistening  white  appearance 
may  be  found  in  the  walls  of  the  vessels,  particularly  in 
connection  with  albuminuric  retinitis.  The  affected  por- 
tion of  the  vessel  appears  as  a  white  band,  and  beyond  it 
the  vessel  may  assume  the  normal  appearance,  or  whole 
vessels  may  be  thus  altered  to  white  streaks.  This  ap- 
pearance is  quite  different  from  that  of  the  faint  gray 
lines  seen  on  either  side  of  the  vessel  where  it  crosses 
another  vessel  or  other  dark  background  upon  the  optic 
disk  ;  and  which  may  also  be  seen  to  extend  beyond  the 
disk,  in  eyes  that  have  been  the  seat  of  retinal  inflamma- 
tion, or  in  vascular  disease. 

Irregularities  of  caliber  arc  noticed  in  the  retinal  vessels, 


360  ALTERATIONS  OF  THE  VESSELS. 

unassociated  with  marked  retinal  disease,  or  great  disturb- 
ances of  the  general  circulation.  They  may  also  be  seen 
after  neuroretinitis  and  as  an  early  symptom  of  renal  vas- 
cular disease,  or  of  grave  disturbances  of  the  cerebral  cir- 
culation or  of  cerebral  hemorrhage.  Pulsation  of  the  ves- 
sels is  elsewhere  discussed.  (See  page  86  and  Chapter  XV.) 

Retinal  hemorrhage  appears  as  one  or  more  dark  red 
spots,  which  slowly  disappear  with  the  decoloration  of  the 
clot,  and  may  be  succeeded  by  white  spots  of  fatty  de- 
generation. Hemorrhage  is  most  frequently  situated  in 
the  nerve-fibre  layer,  where  the  effused  blood  pushes  its 
way  between  the  bundles  of  nerve-fibres;  giving  the 
patch  a  striated  appearance,  especially  noticed  at  the 
margins,  in  the  directions  the  nerve-fibres  run.  Hemor- 
rhages of  this  shape  and  appearance  are  called  flame- 
shaped.  They  are  illustrated  in  Plate  I,  2,  and  Figs.  116 
and  117.  Hemorrhage  into  the  deeper  layers  of  the  retina 
does  not  present  this  appearance,  but  has  a  rounded  edge 
in  all  directions,  and  the  retinal  vessels  may  sometimes 
be  seen  to  cross  in  front  of  it,  although  almost  invisible 
against  such  a  background. 

A  large  patch  of  hemorrhage  hiding  the  retinal  vessels, 
and  having  a  rounded  outline,  especially  liable  to  cover 
the  macula,  and  often  slowly  shifting  position  from  day 
to  day  under  the  influence  of  gravity,  is  called  a  subhya- 
loid  hemorrhage  because  it  is  located  not  in  the  retina  but 
on  its  surface.  Such  a  hemorrhage  may  undergo  complete 
absorption,  with  full  restoration  of  acuteness  of  vision. 
This  rarely  or  never  happens  when  the  hemorrhage  occurs 
in  the  retina. 

Retinal  Opacity  from  Exudate. — The  transparency 
of  the  retina  is  markedly  impaired  by  the  presence  of 
exudate,  even  by  simple  edema.  If  the  swelling  be  great, 
the  normal  red  of  the  fund  us  may  be  entirely  replaced  in 
the  affected  area  by  a  gray  or  bluish  color,  closely  resem- 
bling the  appearance  of  detached  retina.  Above  and 
below  the  optic  disk  where  the  nerve-fibre  layer  is  thick- 
est, the  distribution  of  the  exudate  between  the  nerve- 
fibre  bundles  gives  the  retina  a  striated  appearance,  some- 


DISEASES  OF  THE  RETINA.  361 

what  like  that  of  partial  opaque  nerve-fibers.  In  other 
parts  of  the  retina  the  areas  of  swelling  and  opacity  have 
rounded  outlines,  which  may  be  quite  distinct,  or  the 
patch  may  shade  imperceptibly  into  normal  fundus.  The 
appearances  produced  by  retinal  exudates  are  most  pro- 
nounced in  those  regions  where  the  retina  is  thickest, 
about  the  optic  disk  and  macula,  and  are  scarcely  dis- 
cernible at  the  anterior  peripheral  parts  of  the  retina. 
The  haze  of  retinal  swelling  usually  covers  and  conceals 
portions  of  the  retinal  vessels ;  but  where  the  vessel  lies 
entirely  upon  the  surface  of  the  retina  the  gray  back- 
ground of  the  swollen  retina  causes  it  by  contrast  to  stand 
out  with  unusual  distinctness.  This  is  illustrated  in  Fig. 
116. 

Patty  degeneration  may  take  place  in  the  connective- 
tissue  elements  of  the  retina,  or  in  exudates  into  the  retina, 
and  especially  the  remains  of  hemorrhages.  It  causes 
spots  that  may  have  a  dirty  yellow  or  reddish  hue,  but 
which  in  most  typical  cases  are  pure  glistening  white. 
These  may  be  arranged  in  characteristic  figures,  as  in 
albuminuric  retinitis  and  in  circinate  retinitis. 

Pigment-changes. — The  layer  of  hexagonal  pigment- 
cells  lying  next  to  the  layer  of  the  rods  and  cones  belongs, 
embryologically,  to  the  retina.  It  is  properly  called  the 
retinal  pigment-layer.  Loss  of  its  pigment  renders  visible 
the  vessels  and  intravascular  spaces  of  the  choroid  ;  and 
is  usually  associated  with  choroidal  disease,  as  in  myopia. 
(See  Fig.  63.)  This  pigment  is  always  scanty  at  the 
periphery  of  the  retina,  and  often  becomes  absorbed  as  a 
senile  change.  In  certain  diseases  pigment  is  deposited 
in  the  more  superficial  layers  of  the  retina  and  especially 
along  the  vessels,  covering  portions  of  them  as  with  a 
blanket,  and  to  that  extent  concealing  the  vessels.  (See 
Fig.  118.)  These  pigment-deposits  are  associated  with 
chronic  disease,  or  may  mark  the  site  of  former  hemor- 
rhages. 

Atrophy  of  the  retina  occurs  as  a  sequel  to  diseases 
of  the  retina  or  optic  nerve,  or  both  ;  especially  from 
embolism  or  thrombosis  of  the  central  vessels  of  the 


362  ATROPHY  OF  THE  RETINA. 

retina,  or  atrophy  of  the  optic  nerve.  It  is  indicated  by 
great  diminution  in  the  size  of  the  retinal  vessels,  and 
sometimes  by  absence  of  the  retinal  pigment. 

RETINITIS. 

Simple  retinitis  (edema  of  the  retina,  serous  retin- 
itis) is  characterized  by  more  or  less  opacity  of  the  retina, 
which  may  be  limited  to  a  few  small  spots,  or  may  involve 
a  large  part  of  the  retina  in  the  region  of  the  posterior 
pole.  It  may  affect  one  or  both  eyes.  The  vessels  are 
usually  somewhat  broad  and  tortuous,  some  of  their  curves 
being  veiled  by  the  hazy  retina.  Vision  is  impaired  over 
the  portion  of  the  field  corresponding  to  the  affected 
retina. 

Etiology  and  Diagnosis. — This  disease  may  be  caused 
by  eye-strain,  or  by  unrecognized  constitutional  conditions. 
Other  forms  of  retinitis  often  begin  by  simulating  this 
one,  and  only  acquire  their  special  characters  later.  The 
diagnosis  is  made  by  excluding  the  causes  of  the  special 
forms  of  retinitis.  But  it  is  sometimes  difficult  to  dis- 
tinguish the  haziness  due  to  retinal  swelling,  from  that 
due  to  vitreous  opacity,  or  the  blurring  caused  by  astig- 
matism (see  page  176) ;  and  marked  edema  may  be  mis- 
taken for  detachment  of  the  retina. 

Treatment. — Simple  retinitis  requires  rest  of  the  eyes 
in  a  moderate  and  constant  light ;  often  with  correction 
of  errors  of  refraction,  sometimes  with  the  continued  use 
of  a  mydriatic.  A  mild  purgative  may  be  given,  and  fol- 
lowed by  the  use  of  iodids  in  small  doses.  The  general 
health  should  be  attended  to.  Under  such  treatment 
recovery  is  usually  complete,  if  the  case  be  truly  one  of 
simple  retinitis.  A  few  cases  with  dense  masses  of 
exudate  may  have  corresponding  permanent  scotomas. 

Purulent  Retinitis  (Metastatic  or  Embolic  Retinitis). 
— Clinically  this  disease  cannot  be  distinguished  from 
purulent  choroiditis  (see  page  341),  except  that  it  more  fre- 
quently runs  the  chronic  course  that  results  in  pseudo- 
glioma.  It  is  distinguished  by  the  microscope  after  the 


DISEASES  OF  THE  RETINA.  363 

eye  has  been  enucleated.  It  is  caused  by  wounds,  par- 
ticularly by  foreign  bodies  penetrating  the  cornea  and 
lodging  in  the  vitreous,  without  injury  to  the  choroid ; 
and  by  metastasis  in  the  course  of  puerperal  fever,  py- 
eraia,  etc. 

Sometimes,  in  connection  with  septic  disease,  small 
white  spots  and  hemorrhages  appear  scattered  in  the 
retina,  without  other  inflammatory  symptoms,  or  much 
impairment  of  vision.  This  condition  is  called  septic 
retinitis. 

I/eukemic  Retinitis  or  Neuroretinitis. — Profound 
leukemia,  and  pernicious  anemia,  are  apt  to  be  attended 
by  a  form  of  retinitis  in  which  there  is  great  and  general 


FIG.  116.— Leukemic  retinitis  (if  left  eye.  The  optic  disk  is  entirely  hidden 
by  swelling,  and  ill-defined  light  patches  of  exudate  hide  parts  of  the  retinal 
vessels.  The  macula  is  slightly  affected.  Several  "flame-shaped"  hemor- 
rhages are  shown  by  darker  patches. 

swelling  and  opacity  of  the  retina,  often  extending  upon 
the  optic  disk.  There  is  enlargement  of  the  retinal 
veins,  sometimes  enormous,  and,  in  the  later  stages, 


364  LEUKEMIC  RETINITIS. 

numerous  flame-shaped  hemorrhages.  The  appearances 
are  represented  in  Fig.  116.  If  the  case  be  sufficiently 
chronic  some  of  the  patches  of  more  dense  exudate  may 
show  evidence  of  fatty  degeneration.  The  general  color 
of  the  fundus  is  light  and  often  strikingly  yellow  ;  and  the 
vessels  are  broad  and  pale,  with  visible  sheaths.  Both 
eyes  are  affected,  although  often  to  different  degrees. 

Etiology  and  Diagnosis. — The  essential  cause  is  the 
leukemia,  or  pernicious  anemia ;  and  its  recognition  with 
that  of  the  retinal  changes,  establishes  the  diagnosis. 
Much  the  same  retinal  changes  have  been  seen  in  cases 
of  profound  anemia  from  other  causes,  and  in  connection 
with  hemophilia.  Malarial  disease  of  the  retina  may 
present  much  the  same  appearances. 

Treatment  and  Prognosis. — The  treatment  is  that  of 
simple  retinitis,  with  the  treatment  of  the  leukemia. 
The  retinal  lesions  commonly  appear  late,  and  do  not 
often  improve  much,  continuing  to  grow  worse  until  the 
fatal  termination  of  the  general  disease.  Usually  they 
do  not  cause  blindness.  Improvement  in  the  general 
condition  may  lead  to  great  improvement  in  the  retinal 
swelling,  with  improved  vision. 

Hemorrhagic  Retinitis  (Apoplexy  of  the  Retina}. — 
Sometimes  with  a  history  of  rather  rapid  impairment  of 
vision,  usually  in  one  eye  or  to  a  greater  extent  in  one 
eye  than  the  other,  a  patient  presents  numerous  flame- 
shaped  hemorrhages  scattered  throughout  the  fundus, 
with  some  swelling  and  opacity  of  the  retina.  One  eye 
may  remain  unaffected,  but  usually  both  become  involved, 
although  sometimes  not  the  second  until  months  or  years 
after  the  first.  If  the  case  be  watched,  fresh  hemorrhages 
are  detected  from  time  to  time ;  and  white  or  yellowish 
spots,  or  areas  of  pigment  disturbance,  follow.  The 
optic  disk  may  be  red  and  swollen.  The  retinal  veins 
are  dilated,  but  the  arteries  may  be  rather  small. 

Etiology  and  Diagnosis. — The  disease  is  most  fre- 
quently seen  in  elderly  persons,  although  some  retinitis 
may  accompany  recurring  hemorrhages  in  young  men. 
In  all  cases  it  is  probable  that  the  vessels  of  the  retina 


DISEASES  OF  THE  RETINA.  365 

are  diseased ;  and  the  extra-ocular  vessels,  too,  are  gener- 
ally abnormal.  In  some  of  the  cases  there  is  a  thrombo- 
sis of  the  central  vein  of  the  retina.  But  in  general  the 
causes  are  not  clear.  The  recognition  of  such  a  condition 
as  Bright's  disease  would  of  itself  remove  the  case  into 
another  class.  Some  hemorrhage  is  likely  to  occur  in 
most  forms  of  retinitis. 

Treatment  and  Prognosis. — Rest  of  the  eyes,  pro- 
tection from  strong  light  by  dark  glasses,  and  the  local 
abstraction  of  blood  from  the  temple,  are  recommended. 
Subconjunctival  bloodletting  has  been  tried  by  Cross. 
The  avoidance  of  excitement  and  the  correction  of  any 
abnormality  in  the  circulatory  or  digestive  systems,  are 
of  equal  importance.  But  in  spite  of  treatment,  hemor- 
rhages recur,  and  sight  is  permanently  damaged,  even  in 
young  patients.  In  the  larger  number  of  elderly  patients 
the  eye  is  rendered  practically  blind.  There  is  consider- 
able danger  of  a  subsequent  rise  of  tension,  causing  a  par- 
ticularly intractable  form  of  glaucoma  ;  and  the  probability 
of  death  within  a  few  months  or  years,  especially  from 
cerebral  hemorrhage,  is  relatively  great. 

ATbumintiric  Retinitis  (Renal-vascular  Retinitis, 
Retinitis  of  Bright's  Disease).  —  This  disease  is  chiefly 
encountered  among  elderly  people,  who  come  seeking 
relief  for  impaired  vision.  The  onset  of  the  symptom  is 
often  sudden,  corresponding  with  the  occurrence  of  hemor- 
rhage or  swelling  in  the  region  of  the  macula.  The 
ophthalmoscope  shows  spots  or  patches  of  hemorrhage  or 
fatty  degeneration  scattered  throughout  the  retina ;  or 
grouped  in  certain  portions,  especially  about  the  macula. 
The  retinal  vessels  are  irregular  in  caliber,  especially  the 
veins,  parts  of  which  may  be  dilated  and  tortuous.  Some- 
times the  retina  over  an  extensive  area  about  the  optic  disk 
and  macula  is  greatly  swollen,  and  of  a  dirty  reddish  or 
yellowish  color,  or  even  glistening  white.  Usually  the 
optic  disk  is  reddened  and  its  margin  obscured  by  swell- 
ing. 

Examination  shows  diminished  elimination  of  urine, 
and  the  presence  in  it  of  albumin  and  casts,  although 


366 


ALBUMINURIC  RETINITIS. 


albumin  may  at  times  be  absent,  and  the  casts  not  numer- 
ous. Close  questioning  will  generally  reveal  some  chronic 
impairment  of  health,  especially  nausea  and  headache ; 
and  almost  invariably  the  arteries  throughout  the  body 
show  undue  rigidity,  and  the  pulse  is  tense  though  often 
small. 

Etiology  and  Diagnosis. — In  addition  to  the  causes 
of  simple  inflammation  of  the  retina  this  form  of  retinitis 


FIG.  117.— Albuminuric  neuroretinitis  of  left  eye.  The  disk  is  hidden  by  a 
moderate  vascular  swelling.  The  macula  shows  the  stellate  grouping  of  white 
dots  and  streaks,  and  above  and  below  are  indefinite  patches  of  retinal  exu- 
date.  A  branch  of  the  superior  temporal  artery  directly  above  the  disk  has 
turned  white,  and  there  are  numerous  flame-shaped  hemorrhages.  The  reti- 
nal veins  are  irregularly  dilated. 

clearly  depends  on  the  general  degenerative  changes  of 
grave  renal -vascular  disease.  It  may  occur  in  acute 
Bright's  disease,  after  scarlatina,  in  lead  poisoning,  or 
with  the  albuminuria  of  pregnancy.  But  the  largest 
number  of  cases  occur  in  chronic  interstitial  nephritis,  at 
a  time  when  increased  arterial  tension  can  no  longer  keep 
up  the  normal  excretion  by  the  kidneys,  when  the  ves- 


DISEASES  OF  THE  RETINA.  367 

sels  have  already  undergone  serious  degenerative  changes, 
and  the  evidences  of  grave  disease  are  beginning  to 
appear  elsewhere.  In  the  presence  of  these  general  dis- 
turbances any  evidence  of  retinitis,  or  even  the  mere 
presence  of  isolated  hemorrhages  may  class  the  case  as 
one  of  albuminuric  retinitis. 

The  ophthalmoscopic  appearances  are,  however,  so  typi- 
cal that  an  almost  certain  diagnosis  may  be  based  on  these 
alone.  They  are  illustrated  in  Plate  I,  2,  and  in  Fig.  117. 
Fatty  degeneration  causes  dots  and  larger  areas  of  snowy 
whiteness.  In  typical  cases  these  are  arranged  in  lines 
radiating  from  the  center  of  the  macula,  sometimes  in  all 
directions,  sometimes  only  in  a  limited  sector  of  the  region. 
In  other  parts  of  the  fundus  the  dots  are  scattered  irregu- 
larly, and  are  commonly  less  numerous.  Usually  a  few 
small  scattered  hemorrhages  are  found,  although  they  may 
be  absent  at  a  single  examination.  Sometimes  the  hem- 
orrhages are  large  and  very  numerous. 

The  appearances  in  the  macula  are  sometimes  imitated 
in  optic  neuritis  from  brain  disease.  But  in  those  cases 
there  is  always  great  swelling  of  the  disk.  Albuminuric 
retinitis  may  also  be  attended  with  neuritis.  But  it 
may  present  the  macular  changes  without  material  changes 
in  the  optic  disk ;  and  when  the  disk  is  much  affected 
the  retinal  lesions  are  generally  more  extensive  than  are 
found  in  connection  with  neuritis  from  other  causes. 
Alterations  in  caliber  are  most  pronounced  in  certain 
vessels,  while  others  appear  almost  or  quite  normal. 

Albuminuric  retinitis,  although  not  an  early  symptom 
of  renal-vascular  disease,  may  be  the  first  that  reveals  the 
nature  of  the  case.  In  all  cases  presenting  suspicious 
changes  in  the  retina  the  condition  of  the  kidneys,  heart, 
and  general  circulation,  should  be  carefully  studied. 

Treatment. — As  in  other  forms  of  retinitis  the  eye 
should  have  rest.  Reading  must  be  suspended  or  greatly 
limited.  Errors  of  refraction  or  failure  of  accommoda- 
tion should  be  carefully  met  by  proper  lenses,  to  be  worn 
whenever  the  eyes  are  used.  Beyond  this  the  treatment 
is  that  of  the  general  condition ;  regulated  diet,  woolen 


368  ALBUMINURIC  EETINITIS. 

clothing,  removal  to  a  dry  mild  climate,  and  careful 
avoidance  of  worry,  or  mental  strain.  Internally  strych- 
nin in  moderate  doses  is  sometimes  markedly  beneficial. 
Preparations  of  iron  are  valuable  in  many  cases,  but  may 
do  serious  harm  in  those  showing  a  strong  tendency  to 
develop  fresh  hemorrhages. 

Prognosis. — Occurring  immediately  after  scarlatina, 
with  acute  Bright's  disease,  during  pregnancy,  or  with 
lead  poisoning,  albuminuric  retinitis  may  end  in  recovery, 
often,  however,  not  complete.  Where  it  occurs  with 
chronic  renal-vascular  disease,  if  the  eyes  have  been  much 
strained  as  by  hard  use,  insufficient  help  from  glasses, 
etc.,  complete  rest  of  them  may  be  followed  by  marked 
improvement  of  vision.  But  in  most  cases,  if  the  eyes 
are  used,  repeated  attacks  of  swelling  and  hemorrhage 
occur,  leaving  vision  more  and  more  impaired.  There  is 
a  tendency  sometimes  to  go  on  to  atrophy  of  the  retina 
and  the  optic  nerve  ;  but  most  patients  retain  quite  useful 
vision  until  death.  As  a  sign  of  the  general  disease  and 
the  approaching  fatal  termination  of  the  case,  albumiuuric 
retinitis  is  of  great  significance.  (See  Chapter  XX.) 

Gouty  retinitis  occurs  in  elderly  persons  subject  to 
other  manifestations  of  gout.  It  causes  progressive  im- 
pairment of  vision,  affects  both  eyes,  is  marked  by  yel- 
lowish-white patches  of  exudation  in  the  region  of  the 
macula  and  disk,  hemorrhages  which  occur  chiefly  in  the 
earlier  stages,  thickening  and  opacity  of  parts  of  the 
walls  of  the  vessels,  marked  narrowing  of  parts  of  the 
arteries,  and  dilatation  of  parts  of  the  retinal  veins.  The 
vessels  throughout  the  body  give  evidence  of  marked 
sclerosis.  The  urine  is  of  rather  high  specific  gravity. 
It  contains  a  large  amount  of  uric  acid,  rarely  albumin, 
and  no  casts.  The  treatment  is  that  of  the  gouty  diathesis 
with  rest  for  the  eyes,  and  avoidance  of  excitement. 
Blindness  does  not  usually  occur,  but  there  is  little  or  no 
recovery  of  sight  once  lost ;  and  a  large  proportion  of  the 
patients  die  of  cerebral  hemorrhage. 

Diabetic  retinitis  occurs  in  the  course  of  saccha- 
rine diabetes.  It  is  characterized  by  the  appearance  in 


DISEASES  OF  THE  RETINA.  369 

the  retina  of  small  ivory-white  dots ;  most  numerous 
about  the  macula  and  toward  the  disk,  but  not  arranged 
in  any  stellate  or  regular  figure.  In  a  few  cases  large 
white  plaques  have  been  seen,  toward  the  periphery  of  the 
fundus.  The  optic  nerve  is  not  affected.  Rarely  spots 
of  pigmentation  are  scattered  through  the  fundus. 
Minute  points,  or  larger  spots  of  hemorrhage  are  usually 
seen ;  and  sometimes  typical  hemorrhagic  retinitis  is 
encountered  in  diabetes.  The  treatment  is  that  of  diabetes  ; 
and  the  chance  of  improvement  depends  on  the  chance  of 
improving  the  patient's  general  condition. 

Syphilitic  retinitis  and  chorioretinitis  occur  as 
secondary  lesions  ;  sometimes  rather  early,  but  usually  one 
year  or  more  after  infection.  They  may  run  their  course 
without  perceptible  involvement  of  the  choroid ;  but  in 
the  larger  number  of  cases  there  are  distinct  spots  of 
choroidal  infiltration,  and  later  permanent  atrophic  and 
pigment-changes.  Not  rarely  the  lesions  of  the  posterior 
portions  of  the  eye  accompany  iritis.  There  is  always 
some  opacity  of  the  posterior  part  of  the  vitreous,  dust- 
like  in  character,  gradually  increasing  and  gradually  pass- 
ing away.  (See  Chapter  XIV.)  In  the  choroidal  cases  the 
fundus  is  decidedly  speckled.  Retinal  opacity  is  most 
marked  in  a  zone  around  the  optic  disk,  or  may  be  local- 
ized especially  in  the  macula.  The  optic  disk  is  red, 
hazy,  and  sometimes  quite  obscured,  ultimately  it  may 
present  a  yellowish-white  appearance  of  partial  atrophy. 
The  vessels  are  usually  but  little  altered,  but  may  be 
narrowed  in  the  later  stages.  Retinal  hemorrhage  is  rare. 
In  a  few  cases,  however,  numerous  hemorrhages  of  rather 
large  size  are  distributed  throughout  the  fundus.  Some- 
times the  inflammation  is  localized  at  the  macula,  and 
shows  an  especial  tendency  to  relapse. 

Central  actiteness  of  vision  is  lowered  in  all  cases,  and 
scotomas  of  various  forms  are  apt  to  occur.  There  is 
night-blindness,  excessive  impairment  of  sight  when  the 
illumination  is  slightly  diminished  ;  and  a  persistent  daz- 
zling or  shimmering  of  light  that  is  very  annoying. 
Metamorphopsia  occurs  and  is  likely  to  be  permanent. 

24 


370  SYPHILITIC  RET1NITIS. 

Diagnosis. — The  dust-like  opacity  of  the  posterior 
vitreous,  the  spots  of  gray  or  white,  but  not  brilliant  white 
opacity  of  the  retina,  the  speckled  choroid,  the  red  hazy 
disk,  the  slight  changes  in  the  vessels,  and  the  chronic 
course  of  the  disease  constitute  a  characteristic  picture. 
The  nature  of  the  retinitis  will  be  confirmed  by  a  history 
of  syphilis  or  of  other  characteristic  syphilitic  lesions,  and 
the  absence  of  other  common  causes  of  retinitis.  But  this 
form  of  retinitis  is  one  of  the  most  characteristic  single 
lesions  of  syphilis,  and,  without  other  evidence  of  its 
nature,  should  be  regarded  as  syphilitic. 

Treatment  and  Prognosis. — Iletinitis  of  this  character 
should  be  met  by  the  prompt,  effective,  and  prolonged 
administration  of  mercury.  Inunctions  should  be  given 
at  first.  Subsequently,  some  other  mode  of  administration 
may  be  resorted  to,  but  as  much  should  be  given  as 
possible  without  producing  constitutional  effects.  The 
eyes  should  be  kept  at  rest,  during  the  acute  stage  a 
mydriatic  may  be  used,  and  they  should  be  protected 
from  excessive  light  or  sudden  changes  of  illumination. 
At  a  late  stage  potassium  iodid  may  prove  useful.  Under 
treatment  vision  generally  improves  and  the  disease  is 
permanently  checked ;  but  vision  is  very  rarely  restored 
to  normal,  and  in  most  cases  permanent  retinal  lesions 
are  revealed  with  the  ophthalmoscope. 

Punctate  retinitis  (retinitis  punctata  albescens)  is 
characterized  by  a  great  number  of  white  or  yellowish- 
white  points  scattered  throughout  the  fundus,  without 
pigment-changes.  Vision  is  usually  somewhat  impaired. 
It  is  not  progressive,  and  in  most  recorded  cases  has 
probably  existed  some  time  before  it  was  discovered. 

Striate  retinitis  is  characterized  by  light  yellowish 
or  gray  lines  or  streaks  just  back  of  the  retinal  vessels, 
some  straight  as  though  drawn  upon,  others  curved  or 
with  branching  ends.  The  streaks  have  not  the  direction 
of  the  vessels  or  of  other  known  structures.  The  disease 
appears  in  early  life.  The  streaks  may  mark  a  previous 
detachment  of  the  retina.  Vision  in  the  affected  eye  is 
generally  greatly  impaired,  but  not  entirely  lost. 


DISEASES  OF  THE  RETINA.  371 

Proliferating  Retinitis. — Attacks  of  retinitis  at- 
tended with  extensive  hemorrhages  sometimes  result  in 
the  formation  of  dense  bluish-white  or  gray  masses  of  • 
connective  tissue,  which  extend  from  the  retina  into  the 
vitreous,  hiding  completely  certain  parts  of  the  fundus. 
To  this  condition,  which  is  seen  more  often  as  a  sequel 
than  as  an  active  pathological  process,  the  above  name  is 
applied. 

Circulate  retinitis  is  characterized  by  brilliant  white 
spots  arranged  in  the  form  of  a  wreath  near  the  macula 
or  disk.  They  lie  behind  the  retinal  vessels,  may  remain 
unchanged  for  years ;  and  are  often  accompanied,  and 
perhaps  always  preceded,  by  retinal  hemorrhages.  The 
condition  occurs  mostly  after  middle  life,  and  may  affect 
one  or  both  eyes.  Vision  is  always  impaired,  usually 
growing  worse  gradually. 

Retinitis  from  excessive  light  occurs  from  keep- 
ing the  gaze  fixed  on  the  sun  without  sufficient  protection, 
usually  while  watching  an  eclipse  or  looking  for  sun  spots. 
The  ophthalmoscope  shows  little  or  no  alteration  of  the 
affected  part  of  the  retina,  which  may  not  be  larger  than 
the  fovea.  There  is  a  small  central  scotoma,  persistent, 
annoy  ing,  dazzling,  and  sometimes  metamorphopsia.  The 
injury  may  be  prevented  by  use  of  smoked  glass  so  dark 
that  objects  cannot  be  seen  through  it  by  ordinary  illu- 
mination, and  through  which  the  sun  causes  no  persistent, 
annoying  after-image.  When  the  injury  has  occurred, 
rest  for  the  eyes  and  avoidance  of  sudden  changes  of  illu- 
mination will  be  beneficial.  If  vision  is  not  reduced 
below  one-third,  recovery  of  normal  vision  may  be  ex- 
pected in  from  one  to  six  months,  although  careful  test- 
ing may  still  show  the  presence  of  a  minute  relative  or 
absolute  scotoma. 

Exposure  to  excessive  light  may  be  an  exciting  cause 
of  chorioretinitis,  with  ophthalmoscopie  changes  and 
scotoma.  Such  a  condition  has  followed  exposure  to  a 
stroke  oT  lightning.  Exposure  without  proper  protection 
to  a  powerful  electric,  arc  light,  causes,  besides  the  effects 
of  excessive  light  on  the  retina,  violent  smarting  pain  in 


372 


RETINITIS  FROM  EXCESSIVE  LIGHT. 


the  conjunctiva,  with  swelling  and  inflammation,  probably 
due  to  something  beside  the  light.  The  conjunctiva! 
"symptoms  subside  in  a  few  days.  The  repair  of  the 
retinal  tissue  sometimes  requires  much  longer,  and  may 
not  be  complete. 

Pigmentary  Degeneration  (Retinitis  Pigmentosa).— 
This  is  usually  congenital.  From  early  childhood  night- 
blindness  is  noticed,  the  patient  being  practically  blind  in 
a  feeble  light,  although  no  defect  may  be  noticed  in*good 
daylight.  The  field  of  vision  is  restricted,  usually  con- 


FIG.  118.— Pigmentary  degeneration  of  the  retina.  The  disk  is  white,  the 
retinal  vessels  are  narrowed.  The  rttinnl  pigment  is  atrophied,  revealing 
the  choroidal  vessels.  The  characteristic  pigment-patches  are  seen  in  the 
periphery. 

centrically,  at  first  only  when  in  a  feeble  light.  These 
symptoms  are  slowly  progressive,  the  patient  becoming 
helpless  after  sunset ;  and  the  field  of  vision  greatly  nar- 
rowed, although  full  acuteness  of  central  vision  may  be 
possessed  in  a  good  light. 

The   characteristic   ophthalmoscopic    changes    include 


DISEASES  OF  THE  RETINA.  373 

loss  of  the  normal  pigment  from  the  retinal  pigment- 
layer,  and  accumulations  of  pigment  forming  dark-brown 
or  black  masses  of  a  stellate  or  branching  shape,  compared 
to  that  of  bone-corpuscles.  These  masses  often  lie  along 
blood-vessels,  around  which  they  seem  wrapped  like  a 
blanket.  They  are  first  seen,  and  most  numerous,  in  the 
extreme  periphery  of  the  fundus,  and  gradually  invade 
the  posterior  or  central  portion,  but  rarely  extend  to  the 
immediate  neighborhood  of  the  macula  and  optic  disk. 
They  are  shown  in  Fig.  118.  As  the  case  progresses  the 
retinal  vessels  become  greatly  narrowed,  and  the  optic 
nerve  atrophic.  Both  eyes  are  affected.  Eyes  presenting 
this  form  of  retinal  degeneration  are  often  highly  ame- 
tropic. 

Etiology,  Varieties,  and  Diagnosis. — Congenital  cases 
can  often  be  traced  to  consanguinity  of  parents,  heredity, 
or  inherited  syphilis.  Five  to  ten  per  cent,  of  congenital 
deaf-mutes  suffer  from  this  disease.  A  form  of  the  dis- 
ease is  seen  as  a  tertiary  manifestation  of  acquired 
syphilis.  It  appears  much  later,  often  not  until  middle 
age ;  and  is  attended  by  choroidal  atrophies  and  pigment- 
accumulations.  Cases  may  be  found  presenting  ophthal- 
moscopic  appearances  grading  from  those  of  typical 
chorioretinitis  to  those  of  typical  pigmentary  degenera- 
tion. In  a  few  cases,  the  symptoms  of  which  otherwise 
are  those  of  this  disease,  the  pigment-accumulations  in 
the  retina  are  entirely  lacking.  In  typical  cases  the  nar- 
rowed field,  night-blindness,  slow  progress,  and  ophthal- 
moscopic  symptoms  are  characteristic.  In  the  atypical 
cases  careful  consideration  of  all  symptoms  must  deter- 
mine where  the  case  belongs. 

Treatment  and  Prognosis. — The  treatment  consists 
of  careful  and  very  moderate  use  of  the  eyes  under  the 
best  conditions,  including  the  constant  wearing  of  correct- 
ing glasses,  and  protection  from  excessive  light  and  sudden 
variations  of  illumination.  The  internal  use  of  strychnin 
in  moderate  doses,  the  instillation  of  a  weak  solution  of 
eserin,  and  the  applying  of  the  galvanic  current  to  the 
eyeball  have  been  recommended  as  beneficial.  But  no 


374  PIGMENTARY  DEGENERATION. 

treatment  cures  the  disease,  and  it  is  doubtful  if  anything 
more  than  general  hygienic  measures  delays  its  somewhat 
irregular  progress.  The  majority  of  patients  become 
hopelessly  blind  by  the  age  of  sixty  years.  The  form 
due  to  acquired  syphilis  is  more  amenable  to  treatment ; 
and,  while  running  a  comparatively  rapid  course,  is  not 
so  sure  to  go  on  to  complete  blindness. 

Amaiirotic  Family  Idiocy  (Infantile  Cerebral  De- 
generation, Symmetrical  Changes  at  the  Macula,  Tay*s 
Choroiditis). — This  disease  attracts  attention  during  in- 
fancy or  early  childhood,  by  inability  to  see,  or  general 
progressive  muscular  weakness,  without  evidence  of 
localized  lesions  of  the  nervous  system.  Ophthalmoscopic 
examination  shows  a  rounded  gray  or  white  area  occupy- 
ing the  center  of  each  retina,  with  usually  a  dark-red  or 
brownish-red  spot,  corresponding  to  the  center  of  the 
macula,  somewhat  like  the  appearance  in  embolism  of  the 
central  artery  of  the  retina.  In  a  few  months  the  optic 
nerve  atrophies,  the  patient  becomes  entirely  blind,  and 
the  muscular  weakness  increases,  until  the  disease  ter- 
minates in  death.  Autopsies  show  degeneration  of  the 
large  nerve-cells  of  the  retina  and  the  pyramidal  cells  of 
of  the  cerebral  cortex.  Several  children  of  the  same 
parents  may  be  affected ;  and  the  reported  cases  have 
been  of  Jewish  parentage. 

Angioid  streaks  in  the  retina  are  brown  streaks 
of  pigment,  often  with  lighter  borders,  forming  an  irregu- 
lar network  like  a  system  of  anastomosing  vessels,  but 
not  related  to  the  course  of  the  retinal  or  choroidal  ves- 
sels. The  condition  develops  after  retinal  hemorrhages, 
and  is  attended  with  impairment  of  vision,  which  may 
progress  to  almost  complete  blindness.  No  local  or 
extra-ocular  cause  has  been  found  for  the  condition  ;  and 
no  treatment  other  than  hygienic  measures. 

Bmbolism  of  the  retinal  artery  causes  sudden 
blindness  of  the  eye  affected.  It  occurs  in  connection 
with  cardiac  disease,  or  anourysm,  and  sometimes  where 
the  source  of  the  embolus  is  not  obvious.  The  blindness 
is  complete  if  the  artery  is  wholly  obstructed ;  and  re- 


DISEASES  OF  THE  RETINA.  375 

mains  permanent  unless  the  embolus  becomes  displaced 
and  the  blood-current  re-established.  When  a  single 
branch  of  the  artery  is  affected,  the  field  of  vision  is  cor- 
respondingly limited.  When  the  macula  is  supplied  by 
branches  that  come  off  from  the  retinal  arteries  on  the 
cardiac  side  of  the  obstruction,  or  from  the  unobstructed 
choroidal  or  ciliary  arteries  (cilioretinal  branches),  central 
vision  remains  unimpaired,  but  the  field  of  vision  is 
greatly  narrowed.  If  the  obstruction  continues  a  few 
days,  the  retina  begins  to  undergo  degeneration,  and  sub- 
sequently atrophies. 

Diagnosis. — Retinal  embolism  is  recognized  with  the 
ophthalmoscope.  The  branches  of  the  artery  do  not  at 
first  seem  much  altered  in  appearance,  except  as  they  are 
concealed  by  retinal  opacity.  The  veins  are  in  some 
portions  greatly  narrowed,  and  at  other  points  of  full 
width  or  broadened  by  flattening.  Sometimes  the  slow 
return  of  blood  in  bead-like  or  longer  masses,  may  be 
seen  in  one  or  more  branches  of  the  retinal  veins. 

The  central  portion  of  the  retina  becomes  quite  hazy 
within  a  few  hours  after  the  accident,  giving  that  part  of 
the  fundus  a  bluish-gray  or  white  hue,  except  just  at  the 
fovea  where  is  seen  in  almost  all  cases  a  dark  red  spot. 
The  exudation  and  opacity  may  be  more  dense  along  the 
vessels.  Where  the  vessels  dip  into  it  they  are  partially 
or  wholly  lost  to  view,  and  on  this  account  may  seem  to 
be  narrowed  or  interrupted.  Toward  the  periphery  of  the 
fundus  the  gray  opacity  thins  out  until  the  color  of  the 
fundus  appears  quite  normal.  Retinal  hemorrhages  may 
occur,  especially  in  the  region  of  the  macula. 

The  usual  appearance  of  the  fundus  is  shown  in  Fig. 
119.  After  a  few  days  the  retinal  haze  begins  to  dis- 
appear, but  retinal  degeneration  keeps  the  central  part  of 
the  fundus  white,  with  its  distinct  central  red  spot,  some- 
times for  several  weeks.  At  a  later  stage  there  remains 
only  a  complete  atrophy  of  the  optic  nerve,  with  extreme 
narrowing  or  obliteration  of  retinal  vessels. 

Treatment  and  Prognosis. — In  a  few  cases  the  em- 
bolus  has,  spontaneously,  become  broken  up  or  displaced, 


376 


EMBOLISM  OF  RETINAL  ARTERY. 


and  the  retinal  circulation  partly  or  wholly  restored.  In 
a  few  cases  the  same  result  may  be  brought  about  by 
active  massage  of  the  eyeball,  or  by  temporary  dilatation 
of  the  artery  by  inhalations  of  nitrite  of  amyl.  Both  of 
these  measures  should  be  tried,  and  repeated  two  or  three 
times  a  day  during  the  first  ten  days  or  two  weeks  after 
the  occurrence  of  embolism.  If  they  fail  to  influence  the 


FIG.  119.— Embolism  of  the  central  artery  of  the  retina  9n  the  third  day.  The 
arteries  are  little  altered  in  appearance ;  the  veins  are  irregular  from  partial 
collapse.  The  superior  temporal  vein  shows  the  bead-like  appearance.  The 
center  of  the  fundus  is  gray  with  edema,  except  the  center  of  the  macula, 
which  appears  as  a  dark  round  spot. 

obstruction,  there  is  sometimes  a  partial  re-establishment 
of  the  circulation  through  shrinking  of  the  embolus  or 
relaxation  of  the  arterial  walls,  with  return  of  vision  in 
some  part  of  the  field.  But  generally  the  blindness  is 
permanent.  With  complete  blindness,  after  the  first  two 
or  three  weeks  the  case  must  be  regarded  as  hopeless. 

Thrombosis  of  the  retinal  artery  probably  arises 
in  connection  with   degenerative  changes  in  the  arterial 


DISEASES  OF  THE  RETINA.  377 

walls,  or  spasm  of  the  muscular  coat.  The  symptoms 
resemble  those  of  embolism,  except  that  the  onset  of 
blindness  may  not  be  quite  so  sudden,  or  may  be  attended 
with  temporary  blindness  of  the  other  eye,  giddiness, 
faintness,  or  other  evidence  of  disturbance  of  cerebral  cir- 
culation. Attacks  of  temporary  blindness  through  brief 
arterial  spasm  may  have  preceded  the  thrombosis. 

Thrombosis  of  the  Retinal  Veins. — The  symp- 
toms of  this  condition  resemble  somewhat  those  of  em- 
bolism of  the  retinal  artery.  The  veins  are  enlarged  and 
tortuous,  although  the  arteries  may  be  narrowed.  Hemor- 
rhages are  numerous,  especially  about  the  optic  disk, 
which  may  be  extremely  red.  Loss  of  vision  is  less  sud- 
den than  in  embolism,  and  there  is  more  likely  to  occur 
a  return  of  the  circulation,  at  least  in  some  of  the  vessels, 
and  a  partial  restoration  of  sight.  The  patient  should  be 
kept  quiet,  and  on  a  restricted  diet,  unless  this  is  contra- 
indicated  by  his  general  condition.  Saline  laxatives  may 
be  given,  or  venesection  resorted  to. 

Detachment  of  the  Retina  (Co-arctation  of  the 
Retina,  Amotio  Retince). — Separation  of  the  retina  from 
the  choroid  by  serous  fluid  had  been  before "  noticed  by 
oblique  illumination,  and  in  dissecting  enucleated  eyes. 
But  the  use  of  the  ophthalmoscope  has  shown  it  to  be  a 
not  rare  condition. 

Symptoms  and  Course. — The  detached  portion  of  the 
retina  becomes  blind,  although  in  rare  cases  it  may  re- 
tain light-perception  for  some  time.  It  may  also  suddenly 
cut  off  vision,  by  falling  in  front  of  a  part  still  normal. 
Usually  the  patient  complains  of  sudden  impairment  of 
vision,  which  on  investigation  is  found  to  affect  only  a 
portion  of  the  field.  There  may  for  a  time  be  sufficient 
power  of  vision  retained  in  the  detached  retina  to  allow 
a  noticeable  metamorphopsia,  or  to  cause  annoying  vertigo 
from  displacement,  and  movement  of  the  percipient  ele- 
ments. Any  part,  but  more  commonly  the  anterior  por- 
tion, may  be  the  starting-point  of  detachment.  But  by 
the  gravitation  of  siibretiual  fluid  the  lower  part  of  the 
retina  usually  becomes  affected.  Ultimately  the  whole 


378  DETACHMENT  OF  THE  RETINA. 

retina  is  drawn  away  from  the  choroid,  retaining  only  its 
attachments  at  the  optic  disk  and  its  anterior  margin, 
having  somewhat  the  shape  of  a  straight  trumpet  with 
the  shrunken  vitreous  lying  within  it.  Both  eyes  may  be 
affected,  but  in  the  majority  of  cases  one  escapes.  After 
the  detachment  has  become  complete,  the  lens  often 
becomes  opaque,  and  other  degenerative  changes  occur. 
The  tension  of  an  eye  with  detached  retina  is  likely  to  be 
below  normal. 

With  the  ophthalmoscope  the  retina  appears  as  a  some- 
what opaque,  gray  membrane,  floating  in  rounded  folds ; 
upon  which  may  be  traced  branches  of  the  retinal  vessels, 
apparently  very  small  because  displaced  forward  so  much 
within  the  focus  of  the  lens  through  which  they  are  seen. 
Where  the  retina  is  viewed  obliquely  its  opacity  is  most 
evident.  Through  parts  that  are  nearly  perpendicular  to 
the  surgeon's  line  of  sight  the  red  reflex  of  the  choroid 
may  be  seen.  Where  the  retina  is  but  slightly  and 
recently  separated  from  the  choroid,  no  opacity  may  be 
perceived ;  and  the  detachment  may  be  revealed  only  by 
the  displacement  of  the  retinal  vessels.  Sometimes  dis- 
tinct tears  are  found  in  the  retina,  through  which  the 
choroid  may  be  seen.  Portions  of  the  retina  which  are 
just  becoming  detached  may  exhibit  a  peculiar  fine 
mottled  reflex,  which  may  be  compared  to  the  reflexes 
from  "  pebbled  "  leather.  The  more  striking  appearances 
of  detachment  of  the  retina  are  shown  in  Fig.  120. 

Causes. — Detachment  of  the  retina  occurs  more  fre- 
quently in  men  than  women,  and  the  liability  to  it 
increases  with  age.  It  may  be  caused  by  bruise  or  by 
perforating  wrounds  of  the  eyeball  either  at  once,  or  sub- 
sequently by  cicatricial  changes.  Highly  myopic  eyes 
are  chiefly  liable  to  it,  and  choroidal  disease,  hemorrhage, 
or  an  intra-ocular  growth  may  cause  it.  It  may  appear 
after  a  special  effort,  as  coughing,  vomiting,  or  heavy 
lifting. 

Diagnosis. — Sudden  impairment  of  vision  in  one  eye 
affecting  chiefly  or  solely  a  portion  of  the  visual  field, 
should  always  suggest  this  affection.  With  the  ophthal- 


DISEASES  OF  THE  RETINA.  379 

moscope  its  situation  and  extent  can  usually  be  studied. 
If,  on  account  of  opacity  in  the  cornea,  lens,  or  vitreous, 
this  is  not  possible,  careful  mapping  of  the  field  of  vision 
must  be  relied  on. 

When  detachment  is  recognized,  it  is  necessary  to 
determine  if  the  separation  is  caused  by  fluid  (simple 
detachment)  or  by  a  new  growth,  as  sarcoma  of  the 
choroid.  This  will  be  done  by  noting  the  presence  of 
large  vessels  or  a  distinct  mass  beneath  the  retina,  the 


FIG.  120. — Detachment  of  the  retina,  seen  with  a  strong  convex  lens  which 
focusses  for  the  detached  portion  below,  and  leaves  the  normal  fundus 
above  quite  out  of  focus.  Note  the  rounded  folds  which  float  on  liquid,  and 
the  very  small  retinal  vessels  upon  them. 

absence  of  any  wavy  motion  of  the  retina,  and  the  nor- 
mal or  increased  tension  of  the  globe  in  case  of  new 
growth  ;  or  the  absence  of  any  tumor  visible  through  the 
retina,  the  wavy  movement  and  alteration  in  the  form 
of  the  folds  caused  in  it  by  movements  of  the  eye,  and 
the  normal  or  diminished  tension  in  the  eyeball  in  simple 
detachment.  A  new  growth  concealed  beneath  detached 
retina  which  floats  upon  fluid  surrounding  the  growth  may 
be  revealed  by  strong  illumination,  as  direct  sunlight. 


380  DETACHMENT  OF  THE  RETINA. 

It  is  sometimes  difficult  to  distinguish  between  a  small 
detachment,  and  a  limited  swelling  and  opacity  of  the 
retina  in  retinitis.  Unless  there  be  distinct  folding  or 
floating  of  the  aifected  area,  it  should  usually  be  regarded 
as  swelling  rather  than  detachment,  even  though  the 
pushing  forward  of  the  retina  amounts  to  4.  or  5.  D. 

Treatment. —  This  should  include  rest  in  bed,  with 
absolute  rest  of  the  eyes,  best  under  a  pressure-bandage. 
Pilocarpin  sweats  have  sometimes  proved  of  benefit ;  as 
have  potassium  iodid,  or  salycilic  acid  in  moderate  doses. 
The  injection  of  tincture  of  iodin  or  similar  substances 
into  the  eye  is  not  to  be  recommended.  In  many  cases 
the  withdrawal  of  the  subretinal  fluid  by  an  incision  in 
the  sclera,  has  produced  great  temporary  improvement ; 
but  generally  there  has  been  a  subsequent  return  of  the 
detachment.  Recently  Stillson  has  reported  more  perma- 
nent relief  by  making,  by  the  galvanocautery,  one  or  two 
round  holes  in  the  sclera  beneath  the  detachment. 

Prognosis. — Spontaneous  reattachment  of  the  retina 
occurs  in  rare  cases.  Treatment  fails  to  cure  in  most 
cases.  The  chance  of  recovery,  or  of  the  detachment 
remaining  partial,  is  better  for  traumatic  than  for  spontan- 
eous detachment.  Most  cases  of  detachment  with  high 
myopia  or  choroiditis,  become  total. 

Subretinal  cysticercus  is  seen  occasionally  in  Europe, 
but  no  case  is  reported  in  America.  One  case  of  sub- 
retinal  echinococcus  has  also  been  recorded. 

Glioma  of  the  retina  (or  gliosarcoma)  is  a  malig- 
nant growth  that  occurs  in  early  childhood.  It  may  be 
present  at  birth,  or  appear  during  infancy.  It  affects 
one  or  both  eyes,  and  tends  to  a  fatal  termination  through 
extension  to  the  brain,  or  by  exhaustion. 

Symptoms  and  Course. — Attention  is  first  attracted 
by  a  shining  yellowish-white  reflex  from  back  of  the 
pupil ;  and  the  eye  is  found  to  be  blind.  Beer  called  it 
"  amaurotic  cat's-eye."  The  tumor  grows  rapidly  and  may 
fill  the  globe  in  a  few  months.  As  it  grows,  increase  of 
ocular  tension  occurs,  and  symptoms  of  inflammation 
arise.  The  eye  becomes  red,  painful,  and  tender.  Usually 


DISEASES  OF  THE  RETINA.  381 

it  passes  through  the  same  stages  as  sarcoma  of  the 
choroid  (see  page  350) ;  but  the  first  and  second  stages 
do  not  usually  last  so  long  as  the  corresponding  stages  of 
sarcoma.  The  method  of  extension  is  through  the  optic 
nerve  to  the  brain,  and  by  metastasis  to  other  organs.  In 
a  few  cases  the  inflammatory  symptoms  include  a  severe 
iridocyclitis,  which  may  end  in  diminished  intra-ocular 
tension  and  partial  shrinking  of  the  eyeball.  This  has 
the  effect  of  completely  masking  the  original  disease, 
causing  a  variety  called  cryptoglioma. 

Diagnosis. — Glioma  is  distinguished  from  pseudo- 
glioma  by  growth  of  the  tumor,  by  its  rounded  lobules, 
by  the  presence  of  minute  vessels  upon  it  (although  this 
has  been  simulated  by  pseudo-glioma),  by  the  absence  of 
any  history,  or  cause  of  purulent  choroiditis,  or  retinitis, 
and  by  normal,  and  later  increased  tension,  instead  of  the 
lowered  tension  common  in  pseudo-glioma. 

Treatment. — The  affected  eye  should  be  removed  at 
the  earliest  possible  moment,  with  as  much  of  the  optic 
nerve  as  can  be  taken  with  it.  If  there  is  any  probability 
that  the  growth  has  already  extended  beyond  the  eyeball, 
the  orbital  contents  should  also  be  removed ;  and  it  may 
be  wise  to  remove  and  cauterize  portions  of  the  walls  of 
the  orbit. 

Prognosis. — Removal  while  the  growth  fills  but  a 
small  part  of  the  vitreous  is  likely  to  effect  a  permanent 
cure.  Removal  while  the  growth  is  still  confined  within 
the  globe  offers  a  fair  chance,  one  in  three,  of  cure. 
Removal  after  the  orbital  tissues  are  involved  is  likely  to 
be  followed  by  recurrence.  Operation  is  useless  when  the 
tumor  has  extended  beyond  the  orbit ;  and  without 
removal,  early  death  is  certain. 

Anomalies  of  the  Retina. — The  most  striking  of 
these,  opaque  or  medullatecl  nerve-fibers,  has  been  suf- 
ficiently described  (page  91);  the  characteristic  appearance 
is  shown  in  Fig.  121.  Accumulations  of  pigment  have 
also  been  mentioned  (page  99).  The  arrangement  and 
distribution  of  the  retinal  vessels  varies  greatly.  Some 
of  the  more  common  forms  are  shown  in  Plates  I  and  II 


382 


ANOMALIES  OF  THE  RETINA. 


and  Figs.  72,  84,  87,  90,  and  other  illustrations  of  the 
fund  us. 


PIG.  121.— Medullated  or  opaque  nerve-fibers  in  the  retina  of  the  right  eye. 
Some  parts  of  the  retinal  vessels  are  hidden.  The  striations  take  the  normal 
course  of  the  nerve-fibers. 

BIBLIOGRAPHY. 

Diseases  of  the  Retina.     J.  Schoblj  "  System  of  Diseases  of  the  Eye," 

vol.  iii. 
Sub-hyaloid  Hemorrhage.      J.  H.   Fisher,  "Roy.   Lond.  Ophthal. 

Hosp.  Rep.,"  vol.  xiv.,  pt.  ii. ;  H.  Friedenwald,  "Trans.  Sect. 

on  Oph.  Amer.  Med.   Assoc.,"   1895;   F.  C.  Hotz,   "Ann.  of 

Ophthalmol.  and  Otol.,"  Jan.,  1893. 

Constrictions  and  Dilatations  of  the  Retinal  Arteries.     H.  Frieden- 
wald, "Archives  of  Ophthalmol.,"  April,  1896. 
Unilateral   Albuminuric    Retinitis.      W.    L.   Pyle,    "  Pliila.    Med. 

Jour.,"  Nov.  19,  1898. 
Diabetic  Retinitis.     Oscar  Dodd,  "Archives  of  Ophthalmol.,"  April, 

1895. 
Lesions  of  the  Retina  and  Vessels  Associated  with  Gout.     C.  S.  Bull, 

"Trans.  Cong.  Amer.  Phys.  and  Surg.,''  1897. 
Ophthalmic  Changes  in  Chlorosis,  Pernicious  Anemia  and  Leucocy- 

themia.   C.  A.  Oliver,  "  Trans.  Amer.  Oph.  Soc.,"  1897  ;  "  Annals 

of  Ophthalmol.,"  Jan.,  1898. 


DISEASES  OF  THE  RETINA.  383 

Subconjunctival  Bloodletting  for  Hemorrhagic  Ketinitis.  F.  R.  Cross, 
"Trans.  Oph.  Soc.  of  United  Kingdom,"  July,  1898. 

Hereditary  Congenital  Night- Blindness.  W.  T.  Atwool,  "  Roy.  Lon- 
don Ophthalmic  Hosp.  Rep.,"  vol.  xiv.  pt.  i. 

Amaurotic  Family  Idiocy  or  Infantile  Cerebral  Degeneration.  Carl 
Roller,  "Trans.  Amer.  Ophthalmol.  Soc.,"  1896;  Kingdon  and 
Russell,  "Ophthalmic  Review,"  Dec.,  1897. 

Blinding  of  the  Retina  by  Direct  Sunlight.  Geo.  W.  Mackay, 
"Ophthalmic  Review,"  Jan.-Mar.,  1894. 

Effect  bf  Intense  Flashes  of  Electricity.  Dunbar  Roy,  "American 
Journal  of  Ophthalmol.,"  Dec.,  1897. 

Retinitis  Circinata.  E.  Amman,  "Archives  of  Ophthalmol.,"  Mar., 
1898;  E.  C.  Fisher,  "Trans.  Oph.  Soc.  of  United  Kingdom," 
May,  1898. 

Etiology  of  Retinal  Striation.  L.  Caspar,  "Archives  of  Ophthal- 
mol.," Jan.,  1897. 

Angioid  Streaks  in  the  Retina.  G.  E.  de  Schweinitz,  "  Ophthalmic 
Record,"  July,  1897. 

Embolism  of  the  Central  Artery,  Cilio-retinal  Artery.  O.  F.  Wads- 
worth,  "  Trans.  Amer.  Ophthalmol.  Soc.,"  1896. 

Sudden  Loss  of  Vision  of  Circulatory  Origin.  J.  B.  Barrett,  "Inter- 
colonial Med.  Jour,  of  Australasia.,"  Mar.,  1897. 

Spontaneous  Detachment  of  the  Retina.  C.  Hortsmann,  "Archives 
of  Ophthalmol.,"  Sept.,  1898. 

Detachment  of  the  Retina,  Puncture  of  Sclera  with  Galvano-cautery. 
J.  O.  Stillson,  "Amer.  Jour,  of  Ophthal.,"  May,  1898. 

Detachment  of  the  Retina.  R.  A.  Randolph,  PL  O.  Reik,  C.  A. 
Wood,  L.  F.  Love,  W.  T.  Montgomery,  "Trans.  Section  on 
Ophtlialmol.,  Amer.  Med.  Assoc.,"  1896;  C.  S.  Bull,  "Ophthal- 
mic Review,"  May,  1895;  Wray,  S.  Snell,  Eve,  and  E.  T.  Col- 
lins, "Trans.  Oph.  Soc.  of  United  Kingdom,"  1896. 

Glioma  of  the  Retina.  C.  D.  Marshall,  "  Royal  London  Ophthal. 
Hosp.  Rep.,"  vol.  xiv.  pt.  iii.  ;  H.  Wintefsteiner,  "Ophthalmic 
Review,"  Aug.,  1897;  J.  L.  Thompson,  "Trans.  Sect,  on  Oph- 
thal., Amer.  Med.  Assoc.,"  1898. 


CHAPTER  XIII. 

DISEASES  OF  THE  OPTIC    NERVE,    VISUAL   TRACT 
AND  CENTERS.     AMBLYOPIAS. 

Hyperemia  of  the  Optic  Nerve-head  (Hyperemia 
or  (oiiyextion  of  the  Papilla  or  Optic  Dink}.—  This  is 
shown  by  general  redness  of  the  optic  disk,  and  increase 


384  IfYPKREMIA   OF  THE  OPTIC  XKHVK. 

in  the  number  of  the  smallest  visible  vessels  (see  page  93). 
The  redness  may  be  so  great  that  there  remains  no  con- 
trast.  between  the  disk  and  (he  surrounding  i'undns.  II' 
then;  be  a  distinct  physiological  cup,  the  bottom  of  this  is 
usually  not  reddened,  but  appears  by  contrast  unusually 
white  and  noticeable.  But  the  normal  hue  of  the  optic 
disk  varies  greatly,  so  that  unless  one  has  the  other  < -\  <• 
normal,  or  a  previous  observation  to  make  comparison 
with,  it  is  only  in  marked  eases  that  he  c;m  say  positively 
that  the  nerve-head  is  hyperemic.  Hypereraia  is  caused 
by  strain  of  the  eyes,  whether  from  ametropia,  prolonged 
use,  or  unfavorable  conditions  of  eye-work  ;  by  exposure 
to  strong  light  or  heat,  by  injury,  or  in  inflammation  of 
the  anterior  segment  of  the  eye  (as  a  foreign  body  iu  the 
cornea),  or  conjunctivitis,  and  by  the  causes  of  hyperemia 
and  inflammation  of  the  retina,  or  choroid. 

Anemia  of  the  optic  disk,  or  papilla,  is  as  difficult  to 
estimate  as  hyperemia.  It  causes  the  disk  to  appear 
pale,  comparatively  uniform  in  color  and  devoid  of  small 
vessels.  It  is  a  most  important  symptom  of  optic  atrophy, 
and  may  be  produced  by  general  anemia  or  by  local 
obstruction  to  the  blood-supply.  The  Hurgeon  who  sees 
large  numbers  of  hyperemic  disks  is  liable  to  think  the 
normal  disk  anemic  by  contrast. 

INFLAMMATIONS  OF  THE  OPTIC  NERVE. 

Neuroretinitis  (PajnUordinitis). — Inflammation  of 
the  optic  nerve  always  involves  the  adjoining  retina. 
The  swelling  extends  beyond  the  borders  of  the  nerve, 
and  if  there  is  opacity  it  hides  the  margin  of  the  choroidal 
opening.  Still,  if  this  is  all,  the  case  is  spoken  of  as  one 
of  optic  neuritis.  KVtinilis  extending  to  the  margin  of  the 
disk  veils  and  may  (juite  hide;  the  choroidal  margin  ;  and 
if  not  attended  by  any  swelling  of  the  disk,  it  is  properly 
called  retinitis. 

The  optic  nerve  and  the  retina  forming  one  continuous 
structure,  with  the  closest  anatomic  and  physiologic 
dependences  and  relations,  morbid  processes  all'ecting  the 


DISEASES  OF  THE  OPTIC  NERVE.  385 

one,  frequently  extend  to  the  other,  and  often  the  two 
are  almost  equally  involved.  Any  such  extension,  beyond 
the  limits  above  indicated,  constitutes  the  case  one  of 
neuroretinitis.  Neuroretinitis  occurs  in  connection  with 
renal-vascular  disease,  leukemia,  gout,  syphilis,  lead 
poisoning,  and  sympathetic  ophthalmitis ;  and  severe 
neuritis  arising  in  the  course  of  brain  disease  very  often 
extends  so  largely  to  the  retina,  as  to  warrant  including 
it  under  this  head. 

Optic  Neuritis  (Intra-ocular  Optic  Neuritis;  Papil- 
litis,  Choked  Disk). — Optic  neuritis  is  of  great  importance 
on  account  of  the  evidence  it  gives  of  extra-ocular  disease, 
and  its  liability  to  end  in  optic  atrophy.  It  may  cause 
no  symptoms  apart  from  the  appearances  revealed  by  the 
ophthalmoscope.  Vision  may  be  unaffected  by  even 
violent  neuritis,  and  impairment  of  vision,  when  present, 
may  generally  be  regarded  as  due  to  a  supervening  optic 
atrophy,  rather  than  to  the  neuritis. 

Symptoms  and  Course. — The  essential  symptoms  of 
optic  neuritis  are  increased  vascularity,  swelling  and 
opacity  of  the  nerve-head  extending  beyond  the  margin 
of  the  disk.  With  the  swelling  always  occurs  haziness 
of  the  nerve-head,  so  that  the  margin  of  the  choroidal 
opening,  and  the  deeper  details  of  the  nerve-head,  such 
as  the  lamina  cribrosa,  and  the  deeper  parts  of  the  vessels 
are  blurred  or  hidden. 

Swelling  of  the  nerve-head  is  illustrated  in  Fig.  30. 
It  pushes  forward  the  vessels  which  lie  upon  the  disk  so 
that  their  refraction  as  measured  with  the  ophthalmoscope 
becomes  more  hyperopic.  The  extent  of  the  swelling  is 
estimated  by  comparing  the  refraction  of  the  most  hyper- 
opic of  the  vessels,  with  the  refraction  of  the  nearest  part 
of  the  neighboring  retina,  that  appears  unaffected. 

Usually  this  is  done  in  diopters  of  refraction,  as  a 
swelling  of  7  D.  The  actual  depth  in  millimetres  of 
such  a  swelling  may  be  found  from  the  table  on  page  134. 

When  the  swelling  is  slight,  the  disk  red,  resembling 
in  color  the  general  fundus,  and  the  physiological  cup 
obliterated,  there  may  be  little  beyond  the  convergence 

25 


386 


SYMPTOMS  OF  OPTIC  NEURITIS. 


of  the  retinal  vessels  to  indicate  the  position  of  the  nerve- 
entrance.  As  the  swelling  increases,  however,  it  becomes 
distinctly  more  gray,  and  lighter  than  the  usual  color  of 
the  fimdus,  on  account  of  the  separation  of  the  minute 
vessels  by  exudate. 

When  the  swelling  is  slight,  the  larger  retinal  vessels 
may  be  little  altered  in  appearance,  or  slightly  and  uni- 
formly enlarged.  As  the  swelling  becomes  greater  its 
pressure  upon  them  causes  obstruction  of  the  blood- 
columns,  so  that  the  retinal  arteries  are  narrowed,  while 
the  veins  appear  broad,  dark,  tortuous,  and  often  irregular 
in  caliber.  Something  of  this  appearance  is  illustrated 


FIG.  122.— Optic  neuritis  in  a  case  of  tubercular  meningitis,  right  eye.  Optic 
disk  hidden  by  gray  striated  swelling ;  retinal  veins  very  large  and  tortuous. 

in  Fig.  122  and  in  Plate  II,  8.  These  changes  in  the 
vessels,  with  sharp  limitation  of  the  swelling  to  the  im- 
mediate vicinity  of  the  nerve-entrance,  have  caused  severe 
optic  neuritis  to  be  called  choked  disk. 


DISEASES  OF  THE  OPTIC  NERVE.  387 

In  the  majority  of  cases  of  marked  neuritis,  retinal 
hemorrhages  occur.  Most  frequently  they  are  on  or  near 
the  swollen  nerve-head,  but  sometimes  in  other  parts  of 
the  fundus.  About  the  papilla  they  are  very  notably 
striated,  by  extension,  between  the  bundles  of  nerve- 
fibers.  In  this  situation  it  is  often  not  easy  to  distinguish 
between  a  small  hemorrhage  and  a  dilated  blood-vessel. 
In  severe  neuritis  there  are  often  small  isolated  patches 
of  exudate  in  other  parts  of  the  retina,  particularly  in 
the  direction  of  the  macula.  Extensive  lesions  of  the 
kind  would  place  the  case  in  the  category  of  neuro- 
retinitis. 

Perfect  vision  may  continue  for  weeks  or  months  in 
spite  of  typical  optic  neuritis,  with  great  swelling.  In 
many  cases  the  impairment  of  vision  is  so  slight  as  to 
escape  the  patient's  notice.  But  when  the  secondary 
atrophic  changes  begin,  vision  may  be  lost  very  rapidly. 
The  two  eyes  may  present  very  similar  ophthalmoscopic 
appearances,  and  yet  one  be  practically  blind  while  the 
other  retains  almost  full  vision ;  and  the  difference  be- 
tween the  two  may  be  merely  that  in  the  first  eye  the 
process  is  a  few  days  further  advanced  than  in  the  second. 
Usually,  however,  central  vision  is  somewhat  affected. 
The  patient  complains  of  a  mist  before  the  eyes,  or  of 
persistent  after-images,  and  color-perception  may  be  im- 
paired. Careful  testing  often  shows  an  appreciable  en- 
largement of  the  physiological  blind  spot.  The  concentric 
or  irregular  contraction  of  the  field  of  vision  for  form 
and  color  is  that  described  under  optic  atrophy. 

The  course  of  optic  neuritis  may  be  acute  or  chronic. 
When  dependent  upon  acute  brain  disease,  rheumatism, 
or  suppression  of  menstruation,  it  may  reach  its  height  in 
a  very  few  days.  In  slowly  growing  brain-tumor,  the 
swelling  may  gradually  increase  for  many  months  or  for 
years.  In  either  case  it  tends  to  pass  over  into  a  stage 
of  atrophy.  Although  in  some  of  the  acute  cases  normal 
vision  may  be  preserved,  some  atrophy  of  the  choroidal 
margin,  with  permanent  opacity  of  the  disk  and  in  the 
vessel-walls,  almost  always  remains. 


388  COURSE  OF  OPTIC  XEURITIS. 

Of  the  stage  of  subsidence,  failure  of  vision  may  be  the 
first  sign.  Usually  the  swollen  papilla  becomes  paler, 
and  the  visible  vessels  fewer,  although  some  may  still 
be  noticeably  dilated,  and  meshes  of  new-formed  vessels, 
like  those  seen  after  hemorrhage  in  the  vitreous,  may  ap- 
pear. Fresh  hemorrhages  cease  to  appear,  the  swelling 


FIG.  123.  FIG.  124. 


FIGS.  123, 124.— Optic  neuritis  from  brain  tumor,  right  eye.  FIG.  123  shows  an 
early  stage,  the  disk  obscured  by  swelling.  FIG.  124  shows  the  last  stage  pass- 
ing into  optic  atrophy. 

decreases,  the  hyperopia  of  the  most  prominent  vessels 
gradually  diminishes.  The  vessels  themselves,  especially 
the  veins,  get  smaller,  the  swelling  grows  paler,  the  out- 
lines of  the  optic  disk  begin  to  show  through  it,  and  the 
case  passes  over  into  one  of  consecutive  atrophy  (see 
Plate  II,  9,  and  Fig.  124). 

Diagnosis. — At  the  height  of  a  severe  case,  optic 
neuritis  is  unmistakable.  In  the  earlier  stages  it  must  be 
distinguished  from  normal  prominence  of  the  optic  disk  ; 
and  the  slight  cases  due  to  eye-strain  must  be  separated 
from  those  due  to  more  serious  conditions.  At  one  time 
the  normal  optic  nerve-head  was  supposed  to  usually  pro- 
ject into  the  eye,  and  hence  it  was  called  the  optic  papilla. 
In  some  eyes  this  is  actually  the  normal  condition.  In 
many  eyes  the  most  prominent  vessels  are  hyperopic  1  or 
2  D.  as  they  pass  off  the  disk.  Such  prominence  must 
be  considered  normal,  even  though  the  disk  be  quite  red, 
if  there  be  no  opacity  to  veil  the  disk-margin. 

In  cases  of  eye-strain,  however,  it  not  rarely  happens 
that  with  this  prominence  and  redness  of  the  disk,  there  is 


DISEASES  OF  THE  OPTIC  NERVE.  389 

also  some  "  filling  in  "  of  the  physiological  cup,  and  suffi- 
cient opacity  to  obscure  the  disk-margin,  especially  above 
and  below.  Such  a  case  may  be  regarded  as  one  of  optic 
neuritis.  But  if  the  eye- strain  be  present,  it  may  be 
ascribed  to  that  cause,  unless  symptoms  of  organic  dis- 
ease likely  to  cause  optic  neuritis  be  also  noticeable.  In 
the  latter  case  the  diagnosis  can  only  be  made  by  watch- 
ing the  eye  for  some  days.  If  the  swelling  and  opacity 
increase,  even  though  slowly,  and  the  retinal  veins  be- 
come decidedly  dilated  and  tortuous,  serious  organic  dis- 
ease in  the  brain  or  elsewhere  is  indicated.  The  character 
of  the  optic  neuritis  gives  little  information  of  the  nature 
of  its  cause. 

Etiology  and  Pathology. — The  largest  number  of 
cases  of  well-marked  optic  neuritis  arise  in  connection 
with  organic  disease  of  the  brain  and  its  membranes.  It 
occurs  at  some  time  in  90  per  cent,  of  the  cases  of 
brain-tumor.  Next  in  frequency  comes  meningitis,  then 
abscess,  softening,  thrombosis  of  the  sinuses,  hydroceph- 
alus,  and  rarely  cerebral  hemorrhage.  The  other  known 
causes  are  syphilis,  rheumatism,  renal- vascular  disease, 
lead-poisoning,  suppression  of  menstruation ;  or  inflam- 
mation in  the  orbit,  or  in  the  sphenoidal  or  ethmoidal 
sinuses.  It  may  be  associated  with  the  dropping  of 
watery  fluid  from  the  nostril,  and  has  been  provoked  by 
surgical  treatment  of  the  nasal  passages. 

Optic  neuritis  may  be  caused  by  extension  of  inflam- 
mation from  contiguous  parts ;  and  certain  poisons  cap- 
able of  similarly  affecting  other  nerves  can  cause  optic 
neuritis.  But  its  connection  with  intracranial  disease  is 
not  so  clear.  The  chief  hypotheses  account  for  its  causa- 
tion by  intracranial  pressure  acting  through  the  ophthal- 
mic vein,  or  acting  through  the  lymph-channels  surround- 
ing the  nerve,  and  especially  at  the  point  where  the 
central  vein  of  the  retina  emerges  from  the  optic  nerve. 
Direct  extension  of  the  inflammation  from  within  the 
cranial  cavity  has  been  assumed  as  the  explanation, 
although  microscopical  evidence  of  such  a  process  through- 
out the  nerve-trunk  has  often  been  lacking.  The  trans- 


390  PATHOLOGY  OF  OPTIC  NEURITIS. 

mission  through  the  lymph-channels  of  chemical  substances 
capable  of  exciting  inflammation,  or  of  morbid  influences 
through  vasomotor  or  trophic  nerves,  have  also  been  sup- 
posed to  be  the  active  agencies  in  causing  optic  neuritis ; 
but  of  the  relative  value  and  correctness  of  these  various 
hypotheses,  we  cannot  at  present  judge. 

Treatment. — The  essential  point  is  the  removal  of  the 
cause  of  the  neuritis.  Where  the  cause  is  local,  radical 
local  measures  should  be  resorted  to.  Removal  of  an 
intracranial  growth,  or  even  relief  of  intracranial  press- 
ure without  excision  of  a  growth,  is  commonly  followed 
by  prompt  improvement.  Syphilis  should  be  combated 
by  the  energetic  administration  of  mercury  and  of 
potassium  iodid.  Non-syphilitic  optic  neuritis  is  to  be 
met  by  large  and  increasing  doses  of  potassium  iodid, 
maintained  near  the  limit  of  the  individual  tolerance. 
The  eyes  should  be  allowed  to  rest,  and  should  be  pro- 
tected from  excessive  light  or  sudden  changes  of  illu- 
mination. Tapping  the  sheath  of  the  optic  nerve  just 
back  of  the  eyeball,  reaching  it  from  the  temporal  side, 
has  been  tried  with  doubtful  benefit. 

Prognosis. — The  prognosis  in  optic  neuritis  depends 
upon  its  cause.  When  it  arises  from  incurable  cerebral 
disease,  it  passes  on  into  optic  atrophy  and  blindness. 
When  it  arises  in  connection  with  acute  curable  disease, 
complete  recovery  with  full  vision  is  possible.  The  pros- 
pect is  not  good  for  regaining  sight  already  lost,  except 
in  those  cases  of  monocular  neuritis,  arising  from  rheu- 
matism, cold,  or  local  disease  in  the  orbit  or  neighboring 
bones  or  cavities.  Rapid  loss  of  sight  in  chronic  neuritis 
is  unfavorable.  Narrowing  of  the  visual  field  is  more  sig- 
nificant of  progressive  loss  of  sight  than  is  impairment 
of  central  vision  without  contraction  of  the  field. 

Optic  neuritis  gives  little  indication  regarding  the  issue 
of  the  disease  causing  it,  although  a  severe  chronic  neu- 
ritis points  to  the  continuance  and  probable  progress  of 
its  cause.  In  many  cases  of  cerebral  disease  it  appears 
as  a  late  symptom.  But  sometimes  it  appears  early,  and 
very  slowly  progresses  and  passes  on  to  atrophy. 


DISEASES  OF  THE  OPTIC  NERVE..  391 

Retrobulbar  Optic  Neuritis  (Orbital  Optic  Neu- 
ritis).— There  occur  rare  cases  of  rapid  impairment  of 
vision  in  one  eye,  with  pain  in  and  about  the  orbit,  sore- 
ness on  moving  the  eye,  and  tenderness  when  the  eyeball 
is  pressed  back  into  the  orbit.  With  the  ophthalmoscope 
the  nerve-head,  at  this  time,  appears  normal  or  but 
slightly  swollen  and  hazy.  But  after  several  weeks  or 
months  if  sight  is  permanently  damaged,  the  signs  of 
optic  atrophy  may  appear.  The  impairment  of  vision 
generally  affects  only  one  part  of  the  visual  field,  or 
affects  some  parts  more  than  others. 

Usually  the  disease  runs  an  acute  course  ending  with 
partial  or  complete  recovery  of  vision.  It  is  not  espe- 
cially significant  of  cerebral  or  general  diseases.  It  has 
the  same  causes  as  peripheral  neuritis  affecting  other 
nerves :  as  extension  of  local  inflammation,  cold,  rheuma- 
tism, syphilis,  alcoholic  and  other  poisons,  and  acute  infec- 
tious diseases.  It  may  also  attend  chronic  degenerative 
disease  of  the  central  nervous  system. 

The  treatment  is  the  removal  or  treatment  of  the  cause, 
with  local  blood-letting  at  an  early  stage.  Later  potas- 
sium iodid  may  be  given,  and  still  later  strychnin.  The 
prognosis  should  always  be  guarded,  but  recovery  may 
occur  even  after  several  months. 

A  chronic  retrobulbar  neuritis  is  generally  regarded  as 
the  lesion  in  toxic  amblyopia.  The  disease  is  considered 
under  the  later  name  (see  page  397). 


ATROPHY  OF  THE  OPTIC  NERVE. 

Optic  nerve  atrophy  (Optic  Atrophy  or  Degenera- 
tion of  the  Optic  Nerve)  is  characterized  by  impairment 
of  vision,  contraction  of  the  field  of  vision,  pallor  and 
shrinking  of  the  nerve-head  as  seen  with  the  ophthalmos- 
cope, and  in  some  cases  marked  diminution  in  the  size  of 
the  retinal  vessels. 

Symptoms. — The  failure  of  vision  may  be  rapid  when 
the  atrophy  supervenes  upon  optic  neuritis ;  but  in  other 
cases  is  usually  slow,  sometimes  continuing  progressive 


392 


SYMPTOMS  OF  OPTIC  ATROPHY. 


for  years.  The  patient  may  complain  of  a  cloud  or  mist 
before  him.  The  progress  is  sometimes  rather  rapid,  at 
others  the  condition  may  seem  stationary.  There  may  be 
days  when  the  patient  believes  his  sight  improving.  The 
earliest  positive  symptom  is  marked  contraction  of  the 
field  of  vision,  first  for  colors  and  then  for  form.  The 
contraction  of  the  color-fields  may  go  on  to  complete 
obliteration,  usually  in  the  order  of  their  size,  so  that  the 
patient  becomes  blind  first  for  green,  then  red,  and  later 
for  blue. 

The  appearance  of  the  nerve-head  is  that  of  anemia. 


Fio.  125.— Optic  atrophy  consecutive  to  neuritis,  left  eye.  The  disk  is 
dead-white,  slightly  depressed,  and  surrounded  by  a  rins  of  atrophied  and  dis- 
turbed choroid.  The  retinal  vessels  are  somewhat  irregularly  narrowed. 

The  swelling  caused  by  optic  neuritis  loses  its  red,  becom- 
ing paler  and  gray,  or  the  pink  of  the  normal  disk  gives 
place  to  a  white  or  gray  color ;  and  small  visible  vessels 
become  fewer.  The  margin  of  the  disk,  at  first  hidden 
in  retinitis  or  neuritis,  slowly  becomes  more  distinct, 


DISEASES  OF  THE  OPTIC  NERVE.  393 

losing  even  the  slight  blurring  above  and  below,  which  is 
caused  by  the  passage  of  the  thick  layer  of  normal  nerve- 
fibers  across  it.  The  shrinking  of  the  nerve  does  not 
usually  cause  diminution  in  the  choroidal  opening ;  and 
a  scleral  ring  may  appear  within  it,  around  the  shrunken 
nerve-head.  The  shrinking  is  most  manifest  in  the 
depression  of  the  nerve-head,  described  on  page  97,  in 
which  depression  the  normal  excavation  usually  dis- 
appears (see  Fig.  31).  The  diminution  of  the  retinal 
vessels,  may  at  first  only  affect  the  arteries  (after  neuritis)  ; 
or  may  be  a  very  gradual  shrinkage  of  both  arteries  and 
veins.  It  may  be  absent,  the  retinal  vessels  appearing 
quite  normal.  (Compare  Fig.  125  and  Plate  II,  9  with 
plates  and  figures  representing  the  normal  disk.) 

Causes. — Optic  atrophy  is  caused  by  optic  neuritis, 
and  therefore  by  most  of  the  causes  of  neuritis.  It 
follows  certain  forms  of  retinal  diseases,  especially  syphil- 
itic chorioretinitis,  pigmentary  degeneration,  embolism 
and  thrombosis.  It  may  also  be  caused,  apart  from  neu- 
ritis, by  syphilis,  venereal  and  other  excesses,  impaired 
nutrition  in  old  age,  acute  infections  diseases,  chronic 
poisoning,  malaria,  or  diabetes.  Laceration  of,  or  direct 
pressure  on  the  optic  chiasm  or  optic  tract  by  broken  bone, 
hemorrhage,  or  new  growths,  may  cause  it.  A  very  im- 
portant class  of  cases  arise  in  connection  with  spinal 
sclerosis  and  general  paralysis  of  the  insane.  [See  Plate 
II,  Fig.  10.]  The  optic  atrophy  may  be  the  earliest  lesion, 
appearing  years  before  the  impairment  of  locomotion.  In 
rare  cases  optic  atrophy  is  hereditary,  appearing  in  early 
life,  usually  soon  after  puberty,  in  several  of  the  males 
of  successive  generations.  It  is  probable  that  disturb- 
ances of  circulation  due  to  high  altitude  are  sometimes 
a  factor  in  causation.  Some  cases  must  still  be  called 
idiopathic. 

Varieties.  —  Atrophy  occurring  without  antecedent 
disease  of  the  optic  nerve  or  retina,  as  from  impaired 
nutrition,  or  with  spinal  sclerosis,  is  called  primary 
(i/r<>j>hy.  It  is  marked  by  increased  distinctness  of  the 
details  of  the  optic  disk,  as  the  margins  and  lamina  crib- 


394  VARIETIES  OF  OPTIC  ATROPHY. 

rosa,  while  the  adjoining  portions  of  the  choroid  appear 
unaltered.  The  color  of  the  nerve-head  is  usually  gray. 
The  retinal  vessels  long  remain  of  normal  size,  or  are  but 
slightly  diminished.  The  narrowing  of  the  visual  field  is 
usually  regularly  concentric.  Primary  atrophy  is  com- 
monly bilateral. 

Secondary  optic  atrophy  is  a  term  often  restricted  to 
cases  not  following  neuritis,  as  those  occurring  from  pres- 
sure upon  the  optic  tracts.  The  color  of  the  disks  is 
white,  or  rather  gray,  as  in  primary  atrophy,  and  the 
disk-margins  distinct.  The  visual  field  is  liable  to  show 
scotomas,  or  irregular  interruptions,  the  exact  character 
of  which  depend  on  the  special  cause  of  the  atrophy. 

Consecutive  atrophy  (neuritic,  post-neuritic,  or  post- 
papillitic,  retinitic,  or  choroiditic  atrophy)  is  atrophy  fol- 
lowing optic  neuritis,  or  retinal,  or  choroidal  diseases,  as 
a  later  stage  in  a  continuous  process.  In  post-neuritic 
atrophy  the  disk-margins  may  at  first  be  quite  hidden, 
and  the  nerve-head  swollen,  but  of  a  pale  gray  color. 
Slowly  the  swelling  passes  into  excavation,  the  disk- 
margins  become  more  distinct,  and  the  color  a  more  dead 
white.  The  retinal  veins  are  at  first  large,  but  gradually 
shrink  until  they  bear  nearly  the  normal  proportion  to  the 
shrunken  arteries.  The  nerve-head  is  opaque,  the  lamina 
is  hidden.  The  choroid  about  the  nerve-entrance  is  more 
or  less  atrophic,  with  specks  and  blotches  of  pigment- 
accumulation.  Often  the  area  of  disturbed  and  partly 
atrophied  choroid  forms  an  irregular  ring  around  the  disk. 
The  walls  of  the  retinal  vessels  are  somewhat  thickened 
and  opaque.  Gray  or  white  streaks  extend  on  either  side 
of  the  principal  vessels  beyond  the  margin  of  the  optic 
disk.  The  field  of  vision  is  narrowed,  the  boundary 
being  often  marked  by  irregular  re-entering  angles. 

Retinitic  or  choroiditic  atrophy  may  start  with  slight 
haziness  of  the  disk,  which  remains  opaque,  but  not 
hidden  by  an  opaque  swelling ;  its  color  is  yellowish.  The 
retinal  vessels  become  contracted,  sometimes  extremely 
narrow.  The  choroid  about  the  disk  shows  no  greater 
alteration  than  in  other  parts  of  the  fundus.  The  form 


DISEASES  OF  THE  OPTIC  NERVE.  395 

of  the  field  is  often  affected  by  the  distribution  of  the 
retinal  lesions. 

Simple  atrophy  is  primary  atrophy,  or  secondary 
atrophy,  presenting  similar  appearances.  White 
atrophy  and  gray  atrophy  are  so  called  on  ac- 
count of  the  color  of  the  disk.  This  depends  partly  on 
other  factors,  but  tends  to  white  when  there  is  a  marked 
increase  of  the  interstitial  connective  tissue  of  the  nerve- 
head,  and  to  gray  when  there  is  atrophy  of  the  nerve- 
fibers  without  increase  of  connective  tissue. 

Diagnosis. — The  difficulties  of  deciding  whether  an 
optic  disk  is  abnormally  pale  have  already  been  discussed 
on  pages  96  and  384.  While  the  ophthalmoscopic  appear- 
ances of  advanced  atrophy  are  usually  quite  striking,  it 
is  always  prudent  to  carefully  ascertain  the  acuteness  of 
vision  and  the  extent  of  the  visual  fields  before  making 
a  diagnosis.  Care  must  be  taken  to  exclude  other  condi- 
tions, as  errors  of  refraction  or  opacities  of  the  media, 
that  would  impair  central  vision ;  or  detachment  of  the 
retina  that  might  be  the  real  cause  of  a  limitation  of  the 
field  of  vision.  Very  striking  appearances  of  atrophy 
may  exist  with  full  acuteness  of  vision,  or  a  normal  field. 

Treatment. — In  the  early  stages  the  vigorous  treat- 
ment of  the  cause  is  most  important.  Later  the  use  of 
strychnin  in  ascending  and  full  doses,  either  by  the 
mouth  or  hypodermically  should  be  tried,  and  persisted 
in  for  some  months.  Nitroglycerin  may  prove  of  value ; 
and  inhalations  of  nitrite  of  amyl  repeated  every  day  or 
two  have  seemed  to  benefit.  Strict  attention  to  the  gen- 
eral health  comes  next  in  importance,  and  change  of 
residence,  especially  change  of  altitude,  may  be  tried,  if 
practicable.  The  whole  list  of  "  alteratives  "  have  been 
given  without  showing  marked  influence,  the  iodids  offer- 
ing most  hope  of  benefit.  Galvanism  has  been  advocated ; 
but  its  efficacy  is  doubtful. 

Prognosis. — In  primary  atrophy  this  is  extremely 
grave.  The  atrophy  usually  goes  on  slowly  to  complete 
blindness.  The  prognosis  is  altogether  bad  when  second- 
ary atrophy  succeeds  a  lesion  that  has  already  caused 


396  PROGNOSIS  OF  OPTIC  ATROPHY. 

blindness.  In  consecutive  atrophy  when  the  neuritis  has 
been  due  to  a  continuous  progressive  cause,  brain-tumor, 
little  is  to  be  hoped.  In  other  cases  of  secondary  and  con- 
secutive atrophy  the  prospect  is  better ;  but  generally  the 
most  that  can  be  hoped  for  is  to  retard  or  check  the 
deterioration  of  vision.  In  some  cases  of  atrophy  follow- 
ing acute  disease,  and  with  the  toxic  amblyopias,  positive 
improvement  of  vision  or  complete  restoration  are  to  be 
hoped  for.  The  optic  disk  may  be  very  pale  and  con- 
tinue so,  and  yet  great  improvement  of  vision  may  be 
brought  about.  The  vision  in  the  periphery  of  the  field 
gives  the  most  valuable  prognostic  indication.  If  the 
field  is  progressively  narrowing,  even  though  central 
vision  may  be  unaltered,  the  outlook  is  gloomy.  If  the 
field  of  vision  is  not  narrowed,  even  though  central  vision 
is  greatly  impaired,  one  may  hope  for  improvement. 

OTHER  ORGANIC  CHANGES  IN  THE  OPTIC  NERVE. 

Hyaline  bodies  in  the  nerve-head  (Dmseri)  are 
small,  translucent,  rounded,  multiple  masses,  partly  or 
wholly  hiding  the  nerve-head.  They  are  rare  and  are 
found  mostly  in  eyes  that  have  suffered  serious  damage 
from  disease  of  the  optic  nerve,  retina,  or  choroid ;  but 
they  have  been  noted  in  eyes  otherwise  apparently 
normal. 

Tumors  of  the  optic  nerve  are  rare.  They  are 
generally  benign  myxomas  or  fibromas.  They  develop 
behind  the  eyeball,  usually  begin  in  childhood,  with  im- 
pairment of  vision  that  may  not  be  noticed  until,  without 
pain,  the  eye  begins  to  protrude,  being  pushed  directly 
forward  or  a  little  downward.  The  ocular  movements 
remain  remarkably  good  for  so  much  protrusion.  The 
growth  of  the  tumor  is  very  slow.  With  the  ophthal- 
moscope, some  cases  show  optic  neuritis,  sometimes  with 
great  swelling  and  obstruction  of  the  retinal  vessels. 
This  may  give  place  to  atrophy,  with  great  narrowing 
of  the  vessels. 

The  growth  should  be  excised  as  soon  as  recognized. 


DISEASES  OF  THE  OPTIC  NERVE.  397 

Sometimes  this  can  be  done  without  removal  of  the  eye ; 
but  in  most  cases  the  eye,  which  is  always  blind,  has  been 
enucleated  with  the  tumor.  There  is  little  tendency  to 
recurrence. 

Coloboma  of  the  optic  nerve  or  its  sheath  has 
already  been  sufficiently  described  (page  98). 

TOXIC  AMBLYOPIAS. 

Many  drugs  are  capable  of  causing  impairment  of 
vision  ;  but  with  only  a  few  are  the  effects  so  frequent,  so 
characteristic,  and  so  directly  connected  with  lesions  of  the 
retina  and  optic  nerve  as  to  merit  consideration  here. 
Two  very  distinct  types  of  toxic  amblyopia  are  easily 
recognized,  the  one  most  frequently  associated  with  the 
prolonged  use  of  tobacco,  the  other  best  understood  as 
arising  from  excessive  doses  of  quinin. 

Tobacco  Amblyopia  (Amblyopia  ex  abusa,  Central 
Scotoma,  Retrobulbar  Neuritis). — This  form  of  amblyopia 
occurs  once  in  from  500  to  1000  cases  of  eye-disease.  It 
is  unknown  in  childhood,  very  rare  among  young  men, 
and  among  women.  The  best  recognized  lesion  is  a  de- 
generation of  certain  parts  of  the  optic  nerve,  the  papillo- 
macular  bundle,  including  the  fibers  coming  from  the 
macula  entering  at  the  disk,  at  the  lower  outer  part  of 
the  nerve,  and  becoming  central  in  the  nerve-trunk  about 
the  optic  foramen.  It  is  possible,  however,  that  the 
changes  in  the  optic  nerve  are  secondary  to  changes  in 
the  retina. 

Symptoms. — Attention  is  first  attracted  by  impaired 
vision,  there  being  a  mistiness  at  the  center  of  the  field 
that  obscures  the  object  looked  at.  This  is  more  trouble- 
some in  a  bright  light,  varies  a  good  deal  from  time  to 
time,  and  may  increase  so  fast  as  to  interfere  with 
ordinary  eye-work  in  a  very  few  days.  Usually  both 
eyes  are  similarly  affected.  In  rare  cases,  but  one  may 
suffer.  Careful  testing  always  reveals  a  central  color- 
scotoma  for  green  and  red,  sometimes  very  small,  but 
in  other  cases  extending  from  around  the  fixation-point 


398  TOBACCO  AMBLYOPIA. 

toward  and  sometimes  including  the  blind-spot.  Some- 
times all  colors  are  confused  within  the  central  scotoma, 
or  the  whole  field  for  green  or  red  may  be  swallowed 
up,  rendering  the  patient  quite  color-blind.  In  bad  and 
chronic  cases  the  scotoma  may  become  absolute,  light- 
perception  being  lost  in  the  center  of  the  field.  In  a 
few  cases  there  is  some  narrowing  of  the  periphery  of 
the  visual  field ;  but  this  must  be  regarded  as  rather  acci- 
dental, and  not  a  usual  symptom  of  the  disease. 

The  ophthalmoscope  gives  no  certain  evidence  as  to  the 
presence  of  the  disease  in  the  early  stages.  The  disk 
sometimes  appears  slightly  hazy  and  a  dirty  red,  but  this 
is  not  marked  or  characteristic.  Late,  in  bad  cases,  the 
atrophy  of  the  affected  nerve-fibers,  with  proliferation  of 
connective  tissue,  causes  the  outer,  or  lower  outer,  quad- 
rant of  the  disk  to  become  pale  gray  or  even  greenish. 

The  course  of  the  disease  is  essentially  chronic.  The 
disturbance  of  vision  often  continues  to  get  worse  for 
weeks  or  months,  the  patient  being  beguiled  by  the  days 
of  improvement  to  hope  for  recovery,  or  seeking  relief 
at  the  optician's  by  changes  of  glasses.  .  Finally,  the 
condition  becomes  stationary,  or,  under  proper  treatment, 
vision  slowly  improves  or  returns  to  normal. 

Causes. — Tobacco  may  cause  this  disease  in  whatever 
way  it  gains  entrance  to  the  system,  though  the  larger 
number  of  cases  are  due  to  smoking.  The  amount  re- 
quired varies  greatly  with  different  persons ;  amblyopia 
sometimes  begins  after  the  amount  used  has  been  greatly 
diminished  from  what  was  habitual  when  the  patient  was 
younger.  The  manner  of  using,  as  smoking  before  meals, 
the  kind  of  tobacco,  and  racial  predisposition,  all  influence 
the  liability  to  the  disease.  Besides  the  prolonged  ex- 
posure to  tobacco  and  the  influence  of  age,  causes  of 
impaired  general  nutrition  help  produce  the  disease.  It 
often  arises  after  a  severe  nervous  shock,  or  special  men- 
tal depression  or  emotional  strain,  and  may  accompany 
impaired  digestion,  "  tobacco  heart,"  impaired  power  of 
concentrating  the  mind,  or  sleeplessness. 

Diagnosis. — The  history  of  variable  fogging  of  central 


TOXIC  AMBLYOPIAS.  399 

vision,  not  improved  by  glasses,  and  the  central  scotoma 
for  red  and  green  are  characteristic.  It  only  remains  to 
find  if  the  cause  be  the  use  of  tobacco  or  of  some  other 
toxic  agent,  or  whether  it  is  hereditary  atrophy  or  chronic 
retrobulbar  neuritis  from  cold,  or  attending  spinal  scle- 
rosis. In  the  latter  cases  there  is  more  general  involve- 
ment of  the  field  of  vision  than  in  tobacco  amblyopia, 
especially  contraction  of  the  periphery,  which  may  be 
quite  irregular. 

Treatment. — The  first  point  is  the  complete  avoidance 
of  tobacco  in  every  form,  and  of  all  other  substances, 
especially  alcohol,  liable  to  cause  the  same  lesions.  Next 
every  means  should  be  employed  to  restore  the  general 
health  of  the  patient,  as  sleep,  good  food,  and  relief  from 
strain.  If  the  case  is  seen  while  the  impairment  of  vision 
is  increasing,  potassium  iodid  should  be  given  in  moderate 
doses  for  two  or  three  weeks.  But  the  special  remedy  is 
strychnin,  in  increasing  doses,  until  marked  improvement 
begins  or  the  limit  of  tolerance  is  reached.  Then  the 
dose  arrived  at  should  be  continued  until  recovery  is 
complete,  or,  with  intermissions  of  a  week  or  two,  for 
many  months.  Inhalation  of  nitrite  of  amyl  will  often 
cause  marked  temporary  improvement  in  vision ;  and 
the  internal  use  of  nitroglycerin  may  improve  it  more 
permanently. 

Prognosis. — If  the  case  is  seen  within  the  first  few 
weeks,  and  the  patient  will  abstain  entirely  from  the  use 
of  tobacco  and  alcohol,  complete  recovery  can  generally 
be  brought  about,  and  may  occur  without  other  treat- 
ment. Great  reduction  in  the  consumption  of  these  two 
narcotics  may  be  followed  by  practical  recovery,  but  this 
is  much  less  certain.  Persistence  in  their  use  is  pretty 
sure  to  lead  to  great  impairment  of  vision  or  practical 
blindness,  although  complete  blindness  (through  optic 
atrophy)  is  rare.  Even  after  complete  recovery,  the 
lower  outer  quadrant  of  the  disk  may  continue  very  pale. 
The  disease  sometimes  recurs  if  the  use  of  tobacco  is 
resumed. 

Alcohol  amblyopia  (amblyopia  ex  abusa)  is  essen- 


400  ALCOHOL  AMBLYOPIA. 

tially  the  same  disease  as  tobacco  amblyopia.  In  a  very 
large  proportion  of  cases  it  is  the  joint  action  of  the  two 
poisons  that  causes  the  disease,  but  either  alone  is  capable 
of  causing  it.  The  influence  of  alcohol  may  be  sometimes 
traced,  in  the  occurrence  of  the  amblyopia  at  an  earlier 
age,  in  a  greater  tendency  to  permanent  lesions,  and  in 
liability  to  run  into  complete  atrophy. 

Methyl  alcohol  (wood-alcohofy  drunk  to  intoxication 
sometimes  causes  blindness.  Recovery  may  occur,  or 
there  may  be  temporary  improvement  of  vision,  followed 
after  several  days  by  progressive  loss  of  sight  and  optic 
atrophy.  The  treatment  has  included  pilocarpin  sweats 
and  large  doses  of  potassium  iodid.  Strychnin  may  be 
used  in  the  later  stages. 

lodoform  amblyopia  occurs  in  a  few  cases  after  the 
prolonged  use  of  iodoform  dressings  to  large  raw  surfaces 
from  wounds  or  burns,  or  the  internal  administration  of 
large  doses  of  the  drug.  Its  onset  is  accompanied  by 
other  symptoms  of  iodoform  poisoning,  fever,  a  rapid, 
soft  pulse,  diarrhoea,  headache,  delirium,  disturbed  sensa- 
tions, or  stupor.  In  the  best  reported  cases  the  visual 
disturbance  was  in  the  main  similar  to  that  of  acute 
tobacco  amblyopia.  The  diagnosis  would  be  based  on 
the  presence  of  these  symptoms  with  a  history  of  the  use 
of  iodoform.  The  treatment  is  the  same  as  for  tobacco 
amblyopia,  beginning  with  the  removal  of  the  toxic  in- 
fluence ;  and  the  prognosis  is  equally  favorable. 

Bisulphid  of  carbon  amblyopia  occurs  among 
workmen  who  inhale  the  vapor  of  this  substance  as  used 
in  the  process  of  vulcanizing  rubber.  The  general  symp- 
toms of  the  poisoning  are,  at  first,  vertigo,  irritability,  and 
excitement,  and  later,  dejection,  loss  of  memory,  cutan- 
eous anesthesia,  and  muscular  weakness  and  atrophy. 
The  amblyopia  is  very  similar  to  that  produced  by  to- 
bacco. It  is  to  be  treated  in  the  same  way,  the  important 
point  being  the  avoidance  of  the  continued  inhalation  of 
the  fumes  of  the  poison. 

Nitrobensol,  used  in  making  certain  explosives  and 
perfumes,  causes  amblyopia  among  those  who  work  ex- 


TOXIC  AMBLYOPIAS.  401 

posed  to  its  fumes  and  dust.  The  general  symptoms 
include  headache,  muscular  weakness,  cyanosis,  and  men- 
tal disturbance.  The  disturbance  of  vision  closely  re- 
sembles that  of  tobacco  atnblyopia,  except  that  there  is 
also  contraction  at  the  periphery  of  the  field  of  vision. 
The  pupils  are  dilated,  and  with  the  opththalmoscope  the 
eye-ground  and  vessels  appear  strikingly  darker  than 
normal,  and  the  retinal  veins  large  and  tortuous.  The 
treatment  resembles  that  for  tobacco  amblyopia,  and  the 
prognosis  is  good  if  the  patient  can  escape  further  ex- 
posure. 

Quinin  Atnblyopia  (Quinin  Blindness). — Quinin,  and 
in  larger  doses  the  other  cinchona  alkaloids,  have  the 
power  of  causing  a  characteristic,  temporary  or  permanent 
disturbance  of  the  visual  apparatus.  Twelve  or  fifteen 
grains  of  the  drug  in  divided  doses  has  produced  marked 
temporary  amblyopia  ;  but  the  causative  dose  has  usually 
been  very  large,  often  several  drams. 

Symptoms  and  Course. — General  symptoms  of  quinin 
poisoning,  as  deafness,  ringing  in  the  ears,  fulness  of  the 
head,  headache,  and  unsteadiness  of  gait,  and  sometimes 
visual  hallucinations,  precede  the  amblyopia,  which  may 
be  deferred  for  days.  When  it  comes,  the  onset  is 
often  very  sudden,  and  in  bad  cases  the  blindness  be- 
comes absolute.  This  absence  of  light-perception  may 
last  from  a  few  hours  to  several  weeks.  The  pupils  are 
widely  dilated.  The  ophthalmoscope  shows  great  dimi- 
nution of  the  retinal  vessels,  extreme  anemia  of  the  disk, 
and  sometimes  a  slight  general  opacity  of  the  retina,  with 
a  red-spot  in  the  macula  resembling  embolism  of  the 
retinal  artery. 

After  a  time  vision  for  form  returns.  So  soon  as  it 
can  be  investigated,  the  visual  field  is  found  greatly  con- 
tracted and  color-blind.  Gradually  vision  improves  and 
color-perception  returns,  usually  to  a  narrowed  field.  The 
optic  disks  remain  white,  the  retinal  vessels  greatly  con- 
tracted. Cases  have  been  reported  as  quinin  blindness 
with  a  central  scotoma,  and  without  contraction  of  the 
visual  field.  Their  true  nature  is  doubtful. 

26 


402  QUININ  BLINDNESS. 

Diagnosis. — Quinin  blindness  might  be  taken  for  reti- 
nal embolism  or  thrombosis ;  but  these  attack  but  one 
eye,  while  quinin  amblyopia  affects  both. 

Treatment. — The  administration  of  quinin  must  be 
stopped,  and  bromids  or  hydrobromic  acid  may  be  given 
internally.  Inhalations  of  nitrite  of  amyl  should  be  tried 
cautiously  during  the  first  few  days.  Strychnin  is  to  be 
given  hypodermically  or  in  ascending  doses  by  the  mouth. 

Prognosis. — All  recorded  cases  have  recovered  some 
sight,  although  in  one  it  was  only  ability  to  count  fingers. 
But  after  complete  blindness  even  of  very  short  duration 
there  will  remain  some  permanent  impairment,  especially 
contraction  of  the  visual  fields  ;  and  patients  who  have 
once  suffered  in  this  way  are  liable  to  relapse  after  com- 
paratively small  doses  of  the  drug. 

Salicylic  acid  and  sodium  salicylqte  in  large  doses 
sometimes  cause  amblyopia  quite  like  that  produced  by 
quinin.  It  should  be  similarly  treated. 

Acetanilid  can  also  cause  temporary  blindness  with 
retinal  anemia,  which  should  be  treated  with  nitrite  of 
amyl  and  strychnin. 

The  use  of  a  strong  alcoholic  preparation  of  Jamaica 
ginger  as  an  intoxicant  has  been  quickly  followed  by 
blindness,  which  was  to  a  great  extent  permanent. 

Fllix  mas  sometimes  causes  amblyopia,  but  its  effects 
have  not  been  well  studied. 


CONGENITAL,  HYSTERICAL,  AND  SIMULATED  AMBLY- 

OPIAS. 

Amblyopia,  or  weakness  of  sight,  may  properly  be 
restricted  to  cases  in  which  there  is  no  discoverable 
cause  for  the  impairment  of  vision ;  and  amauroxix  to 
cases  of  blindness  with  equal  absence  of  asoertainable 
lesions.  We  have  used  the  term  toxic  amblyopias  in  con- 
nection with  the  effects  of  certain  poisons,  because  the 
essential  lesions  by  which  they  may  ultimately  be  class- 
ified are  not  yet  established.  A  few  other  conditions  still 
remain  that  are  classified  as  aniblyopias. 


AMBLYOPIAS.  403 

Congenital  amblyopia  of  one  eye,  or  chiefly  affect- 
ing one  eye,  is  often  a  factor  in  the  production  of  squint. 
Less  frequently  it  exists  without  any  fault  of  the  ocular 
movements.  It  may  affect  the  whole  field  of  vision  or 
take  the  form  of  scotoma.  It  may  be  regarded  as  an 
arrest  of  development,  which  might  occur  after  birth, 
since  probably  vision  is  then  only  imperfectly  developed. 

Amblyopia  from  imperfect  focussing  of  the  light 
upon  the  retina  may  be  regarded  as  similar  to  congenital 
amblyopia,  except  that  until  quite  late  in  life  vision  is 
still  capable  of  marked  improvement.  It  is  best  studied 
in  cases  of  high  astigmatism,  in  which  the  giving  of  the 
most  accurate  correcting  lens  will  at  first  leave  vision  quite 
imperfect.  But  with  the  wearing  of  the  correcting  lens 
vision  improves,  at  first  rapidly,  then  more  slowly,  until 
after  many  weeks  or  months  it  may  in  young  persons  rise 
to  normal. 

Congenital  color-blindness  may  also  be  regarded 
as  a  special  form  of  congenital  amblyopia,  although  it 
shows  no  tendency  to  association  with  other  congenital 
anomalies  affecting  vision.  It  has  been  sufficiently  dis- 
cussed (page  49).  It  should  always  be  excluded  before 
regarding  impaired  color-perception  as  a  symptom  of 
disease. 

Hemianopsia,  sector  defects,  and  scotomas 
with  transient  amblyopia  are  sufficiently  considered 
in  relation  to  diagnosis  in  Chapter  II,  and  in  Chapter 
XX.  In  so  far  as  they  are  not  due  to  lesions  of  the  eye 
or  optic  nerve,  they  are  really  symptoms  of  brain  disease. 

Hysterical  amblyopia  and  simulated  ambly- 
opia, although  probably  not  the  same  thing,  are  to  be 
detected  by  the  same  tests ;  and  may  here  be  considered 
together.  The  first  step  in  every  case  is  by  a  thorough 
objective  examination,  including  the  use  of  the  ophthal- 
moscope, skiascopy,  oblique  illumination,  and  careful  ob- 
servation of  the  eye  movements,  to  exclude  all  errors  of 
refraction  or  ocular  diseases,  or  to  recognize  their  share  in 
the  symptoms. 

Tests. — When  amblyopia  of  but  one  eye  is  alleged,  the 


404  HYSTERICAL  AMBLYOPIA. 

best  tests  are  those  which  exclude  the  "  seeing  "  eye  with- 
out the  knowledge  of  the  patient.  This  may  be  done 
(Harlan's  test)  by  placing  a  pair  of  trial  frames  upon  the 
patient,  with  the  correcting  lens  before  the  "  blind  "  eye, 
and  before  the  "  seeing  "  eye  a  strong  concave  or  convex 
spherical  lens.  Or  (the  author's  test)  two  strong  cylin- 
drical lenses  may  be  placed  before  the  "seeing"  eye, 
which  when  turned  a  certain  way  will  give  the  optical 
effect  of  its  correcting  lens.  The  patient  having  been 
convinced  that  he  can  see  through  these  lenses,  one  of 
them  is  turned  without  his  knowing  it  so  that  he  can  see 
nothing  through  them,  and  what  he  reads  is  known  to  be 
seen  with  the  "blind"  eye.  These  tests  enable  one  to 
ascertain  exactly  the  vision  of  the  "  blind "  eye. 

As  another  test  the  patient  may  be  made  to  look  with 
the  stereoscope,  at  a  picture,  or  at  a  word,  part  of  which 
is  seen  by  one  eye  and  part  by  the  other.  Recognizing 
the  whole  word  or  describing  both  parts  of  the  picture, 
proves  vision  with  both  eyes.  Again,  the  patient  may 
be  induced  to  read  colored  letters  through  colored  glasses, 
the  glass  before  the  "  seeing  "  eye  being  of  the  color  com- 
plementary to  that  of  the  letters,  and  rendering  them 
invisible  to  it.  With  any  of  these  tests  one  may  by  cov- 
ering the  alleged  blind  eye  interrupt  vision,  and  demon- 
strate to  the  patient  or  to  a  third  party  that  it  was 
the  "  blind  "  eye  that  saw. 

The  holding  of  a  5  centrad  prism  before  one  eye,  with 
the  base  up  or  down,  produces  such  a  vertical  displace- 
ment of  the  retinal  images  that  the  patient  cannot  "  over- 
come "  it  by  turning  the  eye  to  a  corresponding  extent ; 
and,  if  both  eyes  see,  causes  a  vertical  diplopia.  By 
holding  the  prism  before  the  "  seeing "  eye,  the  patient 
will  usually  say  that  it  makes  a  lamp-flame  look  double, 
not  knowing  that  this  proves  vision  in  the  other  eye 
also. 

The  above  tests  may  be  defeated  by  the  patient  closing 
the  "  blind  "  eye  and  so  recognizing  that  the  other  is  ex- 
cluded from  seeing,  or  that,  with  the  prism  one  image 
disappears. 


AMBLYOPIAS.  405 

A  test  that  is  harder  to  demonstrate  to  others,  and 
which  does  not  give  the  exact  acuteness  of  vision  of  the 
blind  eye,  but  which  nothing  but  violence  preventing  its 
application  can  defeat,  is  the  objective  test  with  prisms. 
If  a  prism  of  6  or  8  centrads  is  placed  before  one  eye 
with  its  base  to  the  temple,  the  eye  with  sufficient  vision 
involuntarily  turns  slightly  toward  the  nose,  to  restore 
the  correspondence  of  the  retina  to  the  images  formed 
upon  it.  No  effort  of  the  patient's  will  can  prevent  this 
movement. 

When  blindness  of  both  eyes  is  claimed,  the  last  test  is 
still  applicable.  The  corresponding  movement,  as  the 
prism  is  placed  or  withdrawn,  shows  with  certainty  the 
existence  of  vision  sufficient  to  perceive  diplopia,  probably 
equal  to  at  least  one-twentieth  of  the  normal  standard.  The 
reaction  of  the  eyes  to  this  test  in  the  different  possible 
cases  are :  If  both  eyes  see,  the  eye  before  which  the 
prism  is  placed  moves,  the  other  remains  fixed,  or  makes 
a  very  slight  tremulous  movement ;  if  one  eye  sees,  and  the 
other  is  blind,  the  prism  before  the  seeing  eye  causes  both 
to  move  equally,  while  before  the  blind  eye  it  causes 
neither  to  move ;  if  both  eyes  are  blind,  the  placing  and 
withdrawing  of  the  prism  cause  no  motion. 

When  it  is  claimed  that  both  eyes  are  weak,  but  not 
blind,  the  vision  should  be  tested  with  various  test-types 
at  different  distances,  care  being  taken  that  the  focussing 
shall  be  equally  good  at  all  distances,  so  that  the  acuteness 
of  vision  should  really  be  the  same.  The  patient  who  reads 
the  40-meter  type  at  4  meters,  can  read  the  2-meter  type 
at  20  centimeters.  The  patient  with  vision  really  imperfect 
will  do  this.  But  with  hysterical  or  simulated  amblyopia, 
tests  at  different  distances  will  show  great  discrepancies. 
The  patient's  vision  is  really  at  least  as  good  as  the 
best  vision  admitted  for  any  distance.  The  above  tests 
are  generally  more  practical  and  more  conclusive  and 
exact  than  the  older  method  of  placing  the  patient  thor- 
oughly under  the  influence  of  ether  and  noting  the 
evidences  of  vision  during  the  period  of  recovery. 

Hysterical  amblyopia  may  also  be  marked  by  hemianop- 


406  HYSTERICAL  AMBLYOPIA. 

sia  or  other  limitations  of  the  field  of  vision,  especially 
a  variable  concentric  narrowing ;  or  there  may  be  color- 
blindness or  reversal  of  the  order  of  the  color-fields. 

BIBLIOGRAPHY. 

Diseases  of  the  Optic  Nerve.     H.  Giflbrd,  "  American  Text-book" ; 

J.  Deyl,  "System  of  Diseases  of  the  Eye,"  vol.  iii. 
Hereditary  Ketrobulbar  Neuritis.      O.  Dodd,  "  Annals  of  Ophthal- 

iiiol.,"  July,  1895. 
Hereditary   Optic  Atrophy.     W.  F.  Norris,    "Trans.  Amer.   Oph- 

thalmol.  Soc.,"  1884. 
Hereditary  or  Congenital  Optic  Atrophy.     S.  Snell.  "Trans.  Oph- 

thalmol.  Soc.  of  United  Kingdom,"  Oct.,  1896. 
Optic  Atrophy,  with  Dropping  of  Watery  Fluid  from  the  Nostril. 

P.  Smith,  "Ophthal.  Keview,"  Jan.,  and  June,  1883. 
Optic  Atrophy.     H.  V.   Wiirdemann,  G.  E.   de  Schweinitz,  C.  W. 

Kollock,  Dunbar  Roy,  B.  A.  Eandall,  and  O.  J.  Short,  "  Trans. 

Sect,   on  Ophthalmol.,   Amer.   Med.   Assoc.,"    1896;    Buzzard, 

"  Brit.  Med.  Jour.,"  Oct.  7,  1893. 

Tumors  of  the  Optic  Nerve.     P.  Braunschweig,   "  Ophthalmic  Ke- 
view," Feb.,  1894. 
Representation  of  Function  of  Vision  in  the  Cerebral  Cortex.     S.  J. 

Sharkey,  "Lancet,"  May  27,  1897. 

Cerebral  Localization.     J.  T.  Eskridge,  vol.  iv,  "  System  of  Practi- 
cal Medicine,"  edited  by  A.  L.  Loomis  and  W.  G.  Thompson. 
Toxic  Amblyopias.     G.  E.  de  Schweinitz,  246  pp.,  Lea  Bros.  &  Co., 

Philadelphia. 
Toxic   Amblyopias.     Casey  A.  Wood,   "Annals  of  Ophthalmology 

and  Otology,"  1892,  and  reprinted,  J.  H.  Parker,  St.  Louis. 
Betrobulbar  Optic  Neuritis.     E.  Nettleship,   "Royal  London  Oph. 

Hosp.  Kep.,"  vol.  xv.,  pt,  i. 
Blindness  from  Drinking  Methyl  Alcohol.   H.  Gifford,  "  Ophthalmic 

Record,"  Sept.,  1899. 
Pathology  of  Experimental   Quinine  Amblyopia.     W.  A.  Holden, 

"Trans.   Amer.  Ophthal.  Soc.,"  1898;  "  Archives  of  Ophthal- 
mol.," Nov.,  1898. 
Tobacco  and  Quinine  Amblyopia.     E.  C.  Ellett,  "  Trans.    Sect,  on 

Ophthalmol.,  Amer.  Med.  Assoc.,"  1898. 
Blindness  Following  the  Intoxicating  Use  of  Jamaica  Ginger.    Hiram 

Woods,  "Ophthalmic  Record,"  Feb.,  18H9. 
Ocular  Evidences   of  Hysteria.     Casey  A.  Wood,  "  Amer.  Jour,  of 

the  Medical  Sciences,"  Jan.,  1899. 
New  Tests  for  Simulated  Monocular  Blindness.     Edward  Jackson, 

"Philadelphia  Med.  Jour.,"  Apr.  16,  1898. 


DISEASES  OF  THE  ANTERIOR  CHAMBER.       407 


CHAPTER  XIV. 

DISEASES  OF   THE  ANTERIOR  CHAMBER,  CRYSTAL- 
LINE LENS,  AND  VITREOUS  HUMOR. 

THE  ANTERIOR  CHAMBER. 

THE  anterior  chamber  is  a  lymph-space  of  varying  size, 
liable  to  alteration  of  the  character  and  amount  of  fluid 
passing  through  it,  to  infection,  and  to  obstruction. 

Depth. — It  is  most  shallow  in  early  infancy  from  the 
undeveloped  condition  of  the  eye,  and  in  old  age  from  the 
increased  size  of  the  crystalline  lens.  It  is  deep  in  apha- 
kia  and  very  deep  in  keratoglobus,  both  from  prominence 
of  the  cornea  and  from  flattening  of  the  iris. 

It  is  often  rather  deep  in  myopia.  It  may  also  be  deep 
in  plastic  inflammation  causing  shrinking  of  the  vitreous 
and  retraction  of  the  lens.  It  appears  deeper  when  there 
is  any  opacity  in  the  cornea. 

The  anterior  chamber  is  found  shallow  in  glaucoma,  in 
cataract  during  the  stage  of  the  swelling  of  the  lens, 
during  parenchymatous  inflammation  of  the  iris,  or  from 
bellying  forward  of  the  iris  after  exclusion  of  the  pupil. 
After  injury  of  the  eye  it  may  be  shallow  from  traumatic 
cataract,  and  is  quite  obliterated  so  long  as  a  perforating 
wound  permits  the  free  escape  of  the  aqueous  humor.  In 
degenerated  shrunken  eyes  it  may  be  very  shallow.  The 
anterior  chamber  is  of  unequal  depth  in  different  sym- 
metrical parts,  from  dislocation  or  partial  absorption  of 
the  lens,  unequal  swelling  of  the  iris,  or  partial  synechia. 

Alterations  of  the  aqueous  humor  occur  in  all 
cases  of  inflammation  of  the  ciliary  body  and  iris.  Tur- 
bidity of  the  aqueous  is  then  a  cause  of  impaired  vision, 
and  may  be  made  out  by  careful  oblique  illumination.  In 
some  cases  a  gelatinous  exudate  occupies  a  large  part  of 
the  chamber  (spongy  iritis).  Hypopyon  has  been  described 
(p.  290)  in  connection  with  corneal  suppuration,  one  of 
its  causes.  The  anterior  chamber  may  contain  crystals  of 
cholesterin. 


408       DISEASES  OF  THE  ANTERIOR  CHAMBER. 

Hyphemia,  or  blood  in  the  anterior  chamber,  appears 
of  a  dark-red  color,  usually  as  a  distinct  mass  in  the  lower 
part  of  the  chamber.  It  may  come  from  the  conjunctival 
limbiis,  during  operation,  or  from  the  iris  or  deeper  parts 
of  the  uveal  treat  from  either  injury  or  disease.  The 
mere  presence  of  blood  in  the  anterior  chamber  is  not  of 
serious  importance.  It  is  grave  only  as  a  symptom  of  the 
cause  of  the  hemorrhage,  or  of  the  impaired  nutrition  of 
the  eye.  When  the  general  nutrition  of  the  eye  is  perfect, 
as  in  cases  of  simple  injury,  the  hyphemia  may  be  removed 
very  rapidly,  a  mass  occupying  the  greater  part  of  the 
chamber  disappearing  in  a  few  hours.  But  in  certain 
diseased  conditions,  as  in  chronic  glaucoma,  a  small 
amount  of  blood  may  remain  without  perceptible  diminu- 
tion for  weeks. 

Infection  of  the  anterior  chamber  gives  rise  to  iritis 
or  keratitis.  Obstruction  is  considered  in  connection 
with  glaucoma,  which  it  causes.  Cysts  and  other  tumors 
of  the  iris  grow  into  the  anterior  chamber ;  and  it  may  also 
contain  a  foreign  body,  cysticercus,  or  filaria. 

DISEASES  OF  THE  CRYSTALLINE  LENS. 

Cataract. — The  most  constant  and  obvious  symptom 
of  disease  of  the  crystalline  lens  is  opacity,  so  that  nearly 
all  such  diseases  come  under  the  term  cataract.  Cataract 
has  been  recognized  to  include  any  opacity  of  the  crystal- 
line lens  or  its  capsule.  But  the  term  has  gained  popular 
currency  almost  wholly  in  connection  with  those  cases  in 
which  an  extensive  opacity  prevents  or  impairs  vision. 
Hence  its  use  in  addressing  the  laity  should  be  restricted 
to  that  meaning,  or  accompanied  by  an  explanation  of  its 
more  inclusive  definition. 

Alterations  of  the  I/ens  by  Age. — Changes  of  con- 
sistence are  described  in  connection  with  accommodation 
and  presbyopia,  pages  124  and  144.  Changes  of  size  are 
taken  up  in  connection  with  glaucoma  (Chapter  XV) ;  here 
changes  of  transparency  are  alone  referred  to.  The  crys- 
talline lens  is  never  perfectly  transparent.  In  childhood 


CRYSTALLINE  LENS.  409 

by  illuminating  the  dilated  pupil  very  obliquely  from  one 
side,  and  looking  at  it  very  obliquely  from  the  other  side, 
one  may  see  a  faint  gray  reflex  from  the  anterior  surface 
of  the  lens,  the  most  striking  portion  having  the  form  of 
a  star,  the  branches  of  which  correspond  with  the  lens- 
sectors.  With  increasing  age  this  reflex  becomes  more 
dense,  until  in  many  elderly  persons  the  appearance  of  the 
pupil  by  ordinary  illumination  is  quite  that  of  gray 
opacity  of  the  lens,  although  the  lens  and  the  patient's 
acuteness  of  vision  may  be  quite  normal.  But  in  addition 
to  this  general  loss  of  transparency,  age  is  attended  with 
a  great  liability  to  distinct  localized  opacities  of  the  crys- 
talline lens.  The  writer  noted  such  opacities  in  77  out  of 
100  patients  upward  of  75  years  of  age.  Yet  such  opaci- 
ties are  not  sufficiently  constant  to  be  regarded  as  a 
necessary  or  entirely  normal  senile  change. 

Senile  Cataract  (Hard  Cataract}. — The  usual  associa- 
tion of  age  with  common  forms  of  cataract  justifies  the 
term  "  senile  cataract,"  while  the  increasing  rigidity  and 
size  of  the  nucleus  which  also  accompanies  age,  gives 
occasion  for  the  term  "  hard  cataract,"  in  contradistinction 
to  "  soft  cataract,"  or  opacity  occurring  in  a  lens  which 
has  no  hard  nucleus. 

Symptoms  and  Course. — The  only  symptom  noticed 
by  the  patient  is  impairment  of  vision.  This  comes  on 
gradually,  sometimes  so  gradually  that  in  one  eye  useful 
vision  may  be  entirely  lost  before  any  impairment  is 
noticed.  In  other  cases  after  a  few  weeks  or  months  of 
rapid  loss  of  vision,  it  may  remain  unchanged  or  even 
notably  improve.  The  whole  field  of  vision  is  equally 
affected,  there  is  no  narrowing  at  the  periphery  of  the 
field,  and  color-perception  remains  relatively  good.  When 
the  opacity  is  not  distributed  equally  throughout  the 
lens,  the  acuteness  of  vision  may  vary,  being  in  one  case 
better  in  a  feeble  light,  and  in  another  case  better  in  a 
strong  light.  The  impairment  of  vision  in  some  cases 
never  goes  so  far  as  to  prevent  the  counting  of  the  fingers 
held  a  few  inches  before  the  eye ;  but  in  others,  the 
patient  may  find  it  difficult  to  recognize  the  direction  in 


410  SENILE  CATARACT. 

which  the  hand  is  moved  before  the  eye,  or  the  direction 
in  which  a  lighted  candle  is  held  before  it.  Light-per- 
ception always  remains. 

The  impairment  of  vision  may  at  first  be  due  to  changes 
in  the  refraction  of  the  lens,  rather  than  opacity.  This 
may  be  an  increased  refraction  at  the  nucleus,  causing 
myopia  with  the  pupil  contracted,  or  negative  aberration 
when  the  pupil  is  dilated.  This  myopia  may  enable  the 
patient  to  read  without  the  convex  lenses  on  which  he 
has  long  been  dependent,  and  hence  is  called  second  ,<?/<•//</. 
But  it  causes  a  corresponding  diminution  of  distant 
vision,  and  often  there  is  enough  opacity  of  the  lens 
attending  it  to  diminish  near  vision  also.  In  other  eyes 
the  refractive  change  produces  irregular  astigmatism, 
which  causes  sectors  of  light  and  shadow  that  resemble 
cortical  opacities  of  the  lens,  and  which  appear  when  the 
light  is  thrown  into  the  eye  from  the  ophthalmoscope 
mirror,  held  at  some  little  distance  as  in  skiascopy.  This 
disturbance  of  refraction  often  causes  marked  monocular 
polyopia,  especially  when  the  pupil  is  dilated.  The 
patient  sees  at  night  several  moons  overlapping  each 
other,  or  sees  a  point  of  light,  like  a  distant  electric  light, 
broken  into  several  separate  irregular  lights,  differing 
from  each  other  in  the  direction  of  their  rays. 

Objectively,  cataract  is  to  be  studied  with  oblique  illumi- 


FIG.  126.— Cortical  cataract.  A.  section  of  lens  showing  position  of  opacities. 
B,  appearance  of  dilated  pupil  by  oblique  illumination.  C,  appearance  with 
the  ophthalmoscope. 

nation  and  the  ophthalmoscope.  By  the  former  the  opacity 
appears  as  a  lighter  mass  against  a  dark  back-ground, 
with  the  latter  the  opacity  appears  black  against  the  red 
fundus-reflex.  (See  Figs.  126-128.)  The  opacity  may 


DISEASES  OF  THE  CRYSTALLINE  LENS.        411 

appear  as  a  diffuse  cloud,  or  as  sharply  limited  masses 
surrounded  by  clear  lens-substance.     These  masses  have 


FIG.  127. — Nuclear  cataract.  A,  section  of  lens.    B,  appearance  of  dilated  pupil 
by  oblique  illumination.    C,  appearance  with  the  ophthalmoscope. 

most  frequently  the  form  of  pyramids,  spicules,  or  striae, 
broadest  toward  the  ciliary  region,  and  with  their  apices 
pointing  toward  the  center  of  the  pupil. 

Eyes  in  which  cataract  is  developing,  generally  show 
evidences  of  eye-strain,  as  pain  after  use,  redness  of  the 
optic  disk,  or  conjunctival  hyperemia.  In  some  cases  the 
eye-strain  must  be  regarded  as  a  cause  of  the  cataract,  in 
others  it  is  an  effect  of  the  increasing  difficulty  of  vision. 
Patients  suffering  with  cataract  find  a  bright  light  annoy- 
ing, because  of  the  diffusion  caused  by  its  shining  on  the 
lens  opacity. 

The  stages  through  which  cataract  usually  passes  when 
the  patient  lives  long  enough  are  : 

Incipient  cataract,  while  the  opacity  is  still  partial, 
and  portions  of  the  pupil  still  remain  clear  enough  to 
give  useful  vision. 

Swollen  cataract,  when  the  opacity  has  become  more 
general  but  is  still  not  complete.  The  lens  at  this  stage 
is  markedly  swollen  by  imbibition  of  fluid,  and  pushes 
forward  the  iris,  making  the  anterior  chamber  shallow. 

Mature  cataract,  when  the  whole  lens  has  grown 
opaque,  and  has  returned  to  about  its  normal  volume. 

Hypermature  cataract,  when  the  lens  is  shrunken, 
hard,  sometimes  partly  calcareous,  and  often  its  capsule, 
thick,  tough,  and  thrown  into  ridges  or  folds.  In  a  very 
few  cases,  a  senile  cataract  has  undergone  spontaneous 
absorption,  or  has  become  dislocated  out  of  the  line  of 
vision,  with  a  restoration  of  sight. 


412  SENILE  CATARACT. 

Varieties. — The  above  different  stages  are  spoken  of 
as  varieties.  In  addition,  we  may  recognize  in  the  earlier 
stages  varieties  based  on  the  location  of  the  opacity,  thus  : 

Nuclear  cataract  is  opacity  of  the  lens-nucleus,  gener- 
ally appearing  as  a  diffuse  clouding,  most  dense  behind 
the  center  of  the  pupil.  It  is  illustrated  in  Fig.  127. 

Cortical  cataract  is  the  term  applied  to  cases  present- 
ing opacities  in  the  lens-cortex.  At  first  there  are  isolated 
needles  or  spicules  of  opacity,  situated  in  either  the  an- 
terior or  the  posterior  cortex  or  in  both.  They  are 
usually  larger  and  more  numerous  in  the  lower  nasal 
quadrant  of  the  lens  than  in  any  other  portion.  Their 
distribution  and  appearance  are  illustrated  in  Fig.  126. 
Cortical  is  the  most  common  form  of  senile  cataract.  In 
the  early  stages,  a  case  may  be  purely  cortical  or  entirely 
nuclear;  but,  in  most  cases  of  nuclear  cataract,  some 
opacities  may  be  found  in  the  cortex,  and  always  the  cor- 
tex becomes  somewhat  opaque  before  maturity. 

Choroidal  cataract  is  the  term  applied  to  cases  in 
which  choroidal  disease  is  followed  by  a  very  slowly 
developing,  diffuse  nuclear  opacity,  of  a  decidedly  brown 
color.  The  nucleus  is  very  brown  and  hard,  and  the 
opacity  often  remains  so  incomplete  that  some  vision  is 
retained  for  many  years.  This  form  occurs  in  myopic 
eyes. 

Black  cataract  those  rare  cases  are  called  in  which  the 
lens  is  a  very  dark  brown ;  so  that  by  oblique  illumina- 
tion the  pupil  looks  black,  and  almost  normal  in  ap- 
pearance, even  when  the  cataract  is  mature. 

Morgagnian  cataract  is  characterized  by  a  hard  nucleus 
surrounded  by  the  fluid  remains  of  the  degenerated  cor- 
tex. The  movable  nucleus  may  be  taken  for  a  dislocated 
lens,  especially  as  the  fluid  in  the  lens-capsule  is  some- 
times comparatively  clear  and  there  may  be  trembling  of 
the  iris. 

Complicated  cataract  is  cataract  in  an  eye  that  has  been 
the  seat  of  other  serious  disease,  as  iritis,  iridocyclitis,  or 
detachment  of  the  retina.  Its  extraction  is  often  ren- 
dered more  difficult  by  extensive  synechias ;  and  the 


DISEASES  OF  THE  CRYSTALLINE  LENS.        413 

prognosis  is  modified  by  the  permanent  damage  the  eye 
may  have  suffered,  apart  from  the  lens-opacity. 

Traumatic  cataract  includes  all  cases  due  to  injury. 
Some  of  these,  developing  slowly,  present  quite  the  char- 
acters of  senile  cataract.  The  injuries  of  the  lens  are 
discussed  in  Chapter  XVII. 

Diagnosis. — Partial  opacity  of  the  crystalline  lens  is 
best  recognized  with  the  ophthalmoscope,  using  a  strong 
convex  lens  behind  the  mirror,  which  should  be  held 
about  the  focal  distance  of  this  lens  from  the  eye.  If  the 
opacity  be  cortical,  it  may  be  concealed  by  the  iris,  unless 
one  looks  obliquely  so  as  to  see  behind  the  iris.  In  nuclear 
cataract,  the  whole  pupil  may  appear  obscured,  until  by 
looking  obliquely  the  periphery  of  the  lens  is  found  clear. 
To  make  a  complete  examination  of  the  lens,  it  is  often 
necessary  to  dilate  the  pupil  with  cocain.  The  ophthal- 
moscopic  examination  should  never  be  omitted  in  a  case 
of  suspected  cataract ;  for  only  thus  can  one  avoid  the 
terrible  blunder  of  allowing  a  patient  to  go  hopelessly 
blind  with  glaucoma  or  optic  atrophy,  while  waiting  for  a 
supposed  cataract  to  ripen. 

When  it  is  ascertained  that  cataract  is  present,  the 
character  and  completeness  of  the  opacity  should  be 
studied  by  oblique  illumination,  especially  with  the  bin- 
ocular magnifier.  The  maturity  of  the  cataract  is  esti- 
mated by  determining  the  depth  of  the  opacity  behind  the 
margin  of  the  pupil ;  usually  by  the  breadth  of  the  shadow 
which  the  iris  throws  upon  it  when  the  light  falls  very 
obliquely  across  the  eye.  If  the  whole  cortex  of  the  lens 
is  opaque,  the  opacity  coining  up  to  the  level  of  the  pupil, 
the  shadow  is  very  narrow.  If  between  the  edge  of 
the  iris  and  the  opacity,  upon  which  the  shadow  is  thrown, 
there  remains  clear  lens-substance,  the  shadow  is  broad. 
The  two  conditions  are  illustrated  in  Fig.  128. 

Another  indication  as  to  the  maturity  of  cataract  is 
found  in  the  peculiar  mother-of-pearl  luster  of  the  surface 
of  the  lens  under  oblique  illumination,  which  is  seen 
when  the  superficial  cortex  begins  to  be  affected  but  has 
not  become  fully  opaque.  Complete  opacity  is  shown  by 


414  DIAGNOSIS  OF  CATARACT. 

a  comparatively  uniform  white  or  gray  appearance  of  the 
whole  pupil. 

When  the  question  of  an  operation  comes  to  be  de- 
cided, care  must  be  taken  to  exclude,  as  far  as  possible, 
other  lesions,  such  as  optic  atrophy  or  detachment  of  the 
retina,  which  would  render  operation  useless.  This  is 
done  by  testing  the  field  of  vision,  and  the  ability  to  tell 


FIG.  128.— Senile  cataract.  A,  partial,  If,  mature,  as  seen  by  oblique  illu- 
mination, the  source  of  light  being  on  the  left.  A  shows  the  broader  shadow. 

the  direction  of  a  light,  (light-projection)  by  holding  a 
candle,  or  the  ophthalmoscopic  mirror  in  different  direc- 
tions before  the  eye  ;  and  by  testing  the  quantitative  light- 
perception  by  turning  a  light-flame  up  and  down,  or  by 
holding  the  candle-flame  or  the  ophthalmoscopic  mirror 
at  different  distances. 

Causes  and  Pathology. — Beyond  a  general  connection 
of  cataract  with  certain  factors,  as  age,  diabetes,  or  dis- 
ease of  the  uveal  tract,  but  little  is  known  of  the  cause* 
of  lens-opacity.  Exposure  to  heat  may  cause  it.  This 
is  most  striking  in  the  case  of  glass-blowers.  Heredity  is 
a  recognized  factor.  Exhausting  disease  will  hasten  the 
development  of  cataract.  So  will  any  extensive  disturb- 
ance of  assimilation.  Cataract  has  followed  epidemics  of 
ergotism  ;  and  experimentally  cataract  has  been  produced 
in  the  lower  animals  by  feeding  with  naphthalin. 

Diabetic  cataract  is  clearly  dependent  upon  diabetes. 
It  usually  presents  a  diffuse  clouding  of  the  lens,  which 
may  grow  worse,  or  better,  with  the  general  condition  of 
the  patient.  The  connection  of  cataract  with  chronic 
Bright's  disease  is  uncertain.  Chronic  dyspepsia  seems  to 
predispose  to  it ;  and  tetany  has  been  observed  to  be 
followed  by  it. 


DISEASES  OF  THE  CRYSTALLINE  LENS.         415 

Traumatic  cataract  becomes  opaque  by  the  imbibition 
of  aqueous  humor,  which  separates  the  lens-fibers  and 
destroys  the  refractive  uniformity  of  the  lens.  At  first, 
in  ordinary  senile  cataract,  spaces  form  between  the  lens- 
fibers,  especially  at  the  junction  of  the  nucleus  and  cor- 
tex, and  at  the  periphery  of  the  lens.  Later,  the  lens- 
fibers  themselves  become  irregular  and  disintegrated. 

Treatment. — The  management  of  immature  or  incip- 
ient^ cataract  is  a  matter  of  more  general  interest  than  the 
extraction  of  mature  cataract,  and  is  of  equal  practical 
importance.  The  first  point  is  to  remove  eye-strain. 
Even  if  this  has  not  been  a  primary  cause  of  the  lens- 
opacity,  it  arises  as  vision  becomes  impaired,  and  influences 
the  eye  unfavorably.  If  the  eye  is  still  capable  of  useful 
vision,  its  ametropia,  including  often  astigmatism  due  to 
lens-changes,  should  be  carefully  corrected ;  and  the 
glasses  may  require  frequent  changes.  The  patient  must 
be  strongly  urged  not  to  use  the  eyes  too  long  or  under 
unfavorable  conditions.  The  impending  danger  of  cata- 
ract should  be  mentioned,  if  necessary,  to  enforce  careful 
use  of  the  eyes.  Exposure  to  excess  of  light,  or  heat 
from  fire  or  lamp,  must  be  avoided.  If  much  discomfort 
is  caused  by  exposure  to  bright  light,  dark  glasses  should 
be  worn,  care  being  taken  to  see  that  they  do  not  cause 
eye-strain  by  irregular  refraction.  If  the  opacity  is 
nuclear,  improvement  of  vision  may  be  secured  by  keeping 
the  pupil  partly  dilated  with  weak  atropin  solution,  instilled 
every  second  or  third  day.  If  the  opacity  is  chiefly  in 
the  peripheral  cortex  and  the  center  of  the  lens  is  clear, 
the  annoying  diffusion  of  light  can  be  reduced  by  keeping 
the  pupil  contracted  with  a  solution  of  pilocarpin,  1  : 500, 
instilled  every  morning,  or  twice  daily.  The  general 
health  of  the  patient,  and  especially  the  digestive  func- 
tions, should  receive  careful  attention.  Tonics  and  out- 
door life  may  exert-  a  notable  influence  in  arresting  or 
retarding  the  progress  of  cataract. 

If  the  patient  lives,  and  the  opacity  increases,  the  time 
comes  when  the  removal  of  the  opaque  lens  must  be  con- 
sidered. If  but  one  eye  is  seriously  affected,  the  cataract 


416  TREATMENT  OF  CATARACT. 

should  not  be  removed  until  it  is  fully  mature ;  then  it 
should  be  extracted,  before  it  passes  into  a  state  of  hyper- 
maturity.  Maturity  is  shown  by  complete  opacity  of  the 
cortex,  disappearance  of  the  mother-of-pearl  reflex  from 
its  surface,  and  reduction  of  the  swelling,  as  shown  by 
increase  in  the  depth  of  the  anterior  chamber  to  the 
normal.  In  this  condition,  the  cataract  is  most  easily 
extracted. 

Ripening  Operations. — When,  however,  both  eyes  are 
affected,  as  soon  as  the  better  eye  becomes  incapable 
of  useful  vision,  so  that  the  patient  is  compelled  to  give 
up  all  ordinary  occupations,  measures  should  be  adopted 
for  the  early  removal  of  the  lens.  Sometimes  ripening 
may  be  hastened  by  massage  of  the  lens.  Indirect  mas- 
sage is  done  by  tapping  the  anterior  chamber,  drawing 
off  the  aqueous  so  that  the  lens  falls  against  the  cornea, 
and  then  stroking  the  cornea  with  a  corneal  spatula,  within 
the  area  of  the  pupil  previously  dilated  with  cocain.  Or 
iridectomy  may  be  done,  and  similar  stroking  of  the  cornea 
over  the  area  of  the  pupil  and  the  coloboma  in  the  iris. 
Direct  massage  is  done  either  with  or  without  iridectomy,  by 
introducing  a  spatula  into  the  anterior  chamber  and  strok- 
ing the  anterior  capsule  of  the  lens.  The  author  prefers 
the  operation  first  mentioned.  After  it,  if  the  lens  has  a 
firm  nucleus,  the  anterior  cortex  rapidly  becomes  hazy 
and  within  two  to  six  weeks  entirely  opaque. 

Even  without  any  such  preliminary  operation  a  cataract 
may  be  removed  before  maturity.  The  special  difficulties 
of  such  removal  are  that  portions  of  the  cortex,  still  clear, 
remain  adherent  to  the  lens-capsule,  and  later  become 
opaque,  preventing  good  vision  until  they  have  become 
absorbed,  or  are  removed  by  an  operation  for  secondary 
cataract ;  and  that  the  swollen  lens  may  require  a  slightly 
longer  corneal  incision.  But  after  fifty  years  of  age  the 
bulk  of  the  lens  can  be  removed  as  nucleus ;  the  cortex 
left,  if  not  in  the  anterior  chamber,  will  cause  no  irrita- 
tion ;  and  the  waiting  even  for  a  secondary  operation  or 
the  absorption  of  the  remaining  cortex  is  not  so  irksome 
after  the  principal  operation  is  safely  past.  In  the  hands 


CRYSTALLINE  LENS.  417 

of  skilful  operators  the  risks  of  extraction  are  not  mate- 
rially increased  by  immaturity  of  the  cataract. 

Mature  or  complete  cataract  is  to  be  treated  by  extrac- 
tion. The  operations  and  the  preliminary  and  after  treat- 
ment are  described  in  Chapter  XIX.  The  writer  prefers, 
for  most  cases,  extraction  without  iridectomy,  as  being  a 
simpler  operation  and  leaving  the  patient  with  slightly 
better  vision  and  less  dependent  on  his  glasses.  But 
when  the  iris  is  very  rigid  or  is  bound  down  by  posterior 
synechise,  or  there  is  a  strong  probability  of  prolapse  of 
the  iris,  because  the  patient  is  restless  and  unruly,  or  the 
eyes  prominent,  extraction  with  iridectomy  is  better. 
Before  doing  extraction,  care  should  be  taken  to  have  the 
patient  in  the  best  physical  condition  that  he  is  capable 
of,  and  to  make  sure  there  is  no  chronic  conjunctivitis,  or 
mucopurulent  accumulation  in  the  lacrimal  passages  that 
will  be  liable  to  infect  the  corneal  wound. 

Glasses. — After  cataract  extraction,  a  secondary  opera- 
tion may  be  necessary  (see  Secondary  Cataract),  and  the 
patient  is  compelled  to  wear  glasses.  If  the  ametropia 
has  been  low  before  the  cataract,  removal  of  the  lens  will 
leave  hyperopia  of  10  to  12  D. ;  and  cataract  extraction 
commonly  leaves  astigmatism  against  the  rule,  which  is 
at  first  very  high,  but  ultimately  diminishes  to  less  than 
3  D.  The  changes  in  refraction  may  continue  for  some 
months,  and  until  they  are  complete,  permanent  glasses 
cannot  be  fitted.  For  near  wrork  convex  3  D.  spherical 
must  be  added  to  the  distance-glasses.  Patients  often 
complain  of  the  distortion  produced  by  their  strong 
glasses,  to  which  on  account  of  their  age  they  become  but 
incompletely  accustomed,  and  only  after  a  long  time. 

When  both  eyes  are  the  seat  of  cataract,  the  second 
should  be  operated  on  when  its  cataract  becomes  mature. 
Both  eyes  should  not  be  risked  by  operation  at  the  same 
time.  But  if  both  cataracts  are  ripe,  and  the  eye  first 
operated  on  does  well,  the  second  operation  may  be  done 
within  a  few  days. 

Prognosis. — Of  persons  over  fifty  years  of  age  who 
show  distinct  opacity  of  the  crystalline  lens,  probably  not 
27 


418  PROGNOSIS  OF  CATARACT. 

more  than  one  in  ten  ever  requires  operation.  The  early 
appearance  of  such  opacity,  and  its  rapid  and  continuous 
increase,  point  toward  a  probable  need  of  extraction  ;  yet 
such  cases  may  at  any  time  cease  to  be  progressive. 
Nuclear  opacity  is  apt  to  be  slowly  progressive,  the  cho- 
roidal  form  rarely  reaching  complete  maturity.  Opacities 
recently  formed,  or  progressive,  are  more  apt  to  be  in- 
definite or  hazy.  Those  that  have  ceased  to  change,  are 
sharply  outlined  in  clear  lens-substance.  But  regarding 
the  progress  of  cataract  there  is  always  great  uncertainty, 
and  a  definite  prognosis  can  never  be  given. 

Cataract  extraction  brings  improved  vision  in  over 
90  per  cent,  of  the  cases  (97  per  cent,  of  the  author's 
cases  of  simple  extraction) ;  but  cataract  occurs  in  eyes 
not  otherwise  entirely  healthy,  so  that  full  vision  is  only 
attained  exceptionally,  even  with  the  strong  convex  lenses 
they  require.  The  means  of  excluding  cases  not  likely 
to  be  benefited  are  given  under  diagnosis.  If  light-pro- 
jection and  quantitative  perception  are  defective,  removal 
of  the  cataract,  however  successful,  will  not  improve 
vision,  except  in  a  few  cases  in  which  the  opacity  is 
extremely  dense.  The  extraction  of  a  hypermature 
cataract  is  liable  to  be  followed  by  inflammation  of  the 
uveal  tract,  and  a  poor  visual  result. 

After  cataract  extraction,  vision  generally  becomes 
impaired  through  thickening  of  the  capsule,  (secondary 
cataract),  unless  the  operation  for  this  condition  has  been 
done  shortly  after  the  extraction.  In  about  1  per  cent, 
of  cataract  extractions,  glaucoma  follows,  especially  after 
operations  for  secondary  cataract.  Patients  that  have  suf- 
fered from  cataract  are  quite  as  liable  as  others  of  their 
age  to  choroidal  disease,  optic  atrophy,  and  detached 
retina. 

Juvenile  or  Soft  Cataract. — Cataract  occurring  in 
young  persons  is  usually  devoid  of  a  firm  nucleus,  such 
nucleus  as  existed  in  the  lens  having  been  broken  down  by 
the  degenerative  process.  It  presents  the  appearance  of 
senile  cataract,  except  that  the  pupil  is  apt  to  appear  more 
white  and  uniform  in  color.  A  perfectly  uniform  milky 


DISEASES  OF  THE  CRYSTALLINE  LENS.        419 

appearance  indicates  a  fluid  cataract.  Soft  cataract  is  com- 
monly traceable  to  a  distinct  cause.  A  few  cases  are  con- 
genital ;  some  are  due  to  traumatism ;  some  are  probably 
due  to  convulsions,  at  least  the  association  of  soft  cataract 
with  previous  general  convulsions  is  common ;  diabetes 
causes  some  cases ;  a  few  seem  due  to  early  senile 
changes  in  the  lens. 

Treatment. — Soft  cataract  does  not  usually  require 
extraction.  If  largely  fluid,  an  incision  5  to  8  mm.  long 
in  the  cornea,  with  a  similar  shorter  incision  in  the  ante- 
rior capsule,  will  allow  it  to  be  pressed  out,  or  drawn  out 
through  a  suction  currette.  If  more  consistent,  it  may 
be  opened  by  discission  and  allowed  to  undergo  absorption, 
the  process  being  hastened  from  time  to  time  by  repeat- 
ing the  needling;  any  part  remaining  unabsorbed  may 
afterwards  be  extracted.  No  fixed  age  can  be  set,  up  to 
which  needle  operations  to  produce  absorption  are  proper, 
and  after  which  extraction  must  be  done ;  but  generally 
before  twenty  absorption  can  be  relied  on,  and  after  thirty 
it  is  rarely  sufficient.  In  doubtful  cases  we  may  begin  by  a 
needle  operation  that  makes  but  a  small  opening  in  the 
anterior  capsule,  being  prepared  to  follow  it,  if  necessary 
by  extraction. 

Partial  Cataract. — All  lens-opacities  are  at  some 
time  partial ;  but  in  some  cases  a  fixed  and  characteristic 
portion  of  the  lens  is  involved,  and  there  is  no  tendency 
to  extension  of  the  opacity  to  other  parts,  for  many  years, 
or  throughout  life.  Such  opacities  often  aifect  both  eyes. 
Cataracts  of  this  kind  are  named  by  the  characteristic 
form  or  situation  of  the  opacity. 

Anterior  polar  cataract  (anterior  capsular  cataract 
or  pyramidal  cataract)  occurs  at  the  anterior  pole  of  the 
lens,  involving  the  capsule,  and  is  usually  somewhat  pyra- 
midal in  shape.  It  may  be  congenital,  possibly  the 
remains  of  pupillary  membrane  ;  or  it  may  be  acquired  in 
early  childhood  through  perforation  of  the  cornea.  (See 
page  280.)  Anterior  polar  cataract  is  usually  but  a  small 
speck  upon  or  beneath  the  surface  of  the  lens,  which  does 


420  ANTERIOR  POLAR  CATARACT. 

not  sufficiently  obstruct  the  pupil  to  require  treatment. 
Its  appearance  and  location  are  illustrated  in  Fig.  129. 


o 


FIG.  129.— Anterior  polar  or  pyramidal  cataract.  A,  section  showing  project- 
ing opacity  on  anterior  surface  of  lens.  B,  pupil  by  oblique  illumination.  C, 
pupil  by  ophthalmoscopic  illumination. 

Posterior  polar  cataract  may  be  congenital,  arising 
from  incomplete  clearing  of  the  point  at  which,  during 
fetal  life,  the  hyaloid  artery  reaches  the  posterior  capsule 
of  the  lens.  This  form  consists  of  a  small  rounded 
opacity  situated  to  the  nasal  side  of  the  posterior  pole 
of  the  lens,  and  only  discovered  with  the  ophthalmoscope, 
with  which  it  appears  as  a  small  black  dot  against  the  red 
fundus-reflex.  Another  form  is  a  larger  mass  of  opacity, 
often  of  a  radiating  figure,  which  developes  in  connection 
with  high  myopia,  choroidal  disease,  or  chronic  retinal 
disease ;  and  which  may  progress  to  complete  cataract. 
This  form  interferes  some  with  vision.  It  is  illustrated 
in  Fig.  130. 


D 


FIG.  130.— Posterior  polar  cataract.  A,  section  showing  opacity  just  within 
the  posterior  capsule.  B,  appearance  of  dilated  pupil  by  oblique,  and  C,  by 
ophthalmoscopic,  illumination. 

I/amellar  Cataract  (Zonular  or  Perinuclear  Cata- 
racf). — In  this  form  there  is  opacity  of  a  layer  surround- 
ing the  nucleus,  the  nucleus  within  and  the  cortex  outside 
this  layer  remaining  clear.  This  distribution  of  the  opacity, 
and  the  appearances  it  causes  are  illustrated  in  Fig.  131. 


DISEASES  OF  THE  CRYSTALLINE  LENS.        421 

In  rare  cases  there  are  two  such  complete  concentric 
zones  of  opacity,  separated  by  clear  lens-substance.  More 
frequently,  the  periphery  of  the  lens  presents  commencing 
opacity  of  a  second  layer ;  such  partial  opacities  are  called 
"  riders."  The  appearances  of  lamellar  cataract  resemble 
those  of  nuclear  cataract  in  that  both  present  a  circle  of 
opacity  at  the  center  of  the  pupil,  surrounded  by  clear 


FIG.  131.— Lamellar  cataract.     A,  section  of  lens.    B,  pupil  dilated  seen  by 
oblique,  and  C,  by  ophthalmoscopic,  illumination. 

lens-substance.  But  they  differ  in  that  in  lamellar  cataract 
the  opacity  is  most  dense  at  the  margin  of  the  circle,  while 
in  nuclear  cataract  it  is  most  dense  at  the  center. 

This  form  of  cataract  is  congenital,  or  arises  in  early 
childhood.  It  is  often  associated  with  a  history  of  con- 
vulsions, dental  defects,  or  other  congenital  deficiencies 
of  the  eyes. 

Fusiform  cataract  is  a  spindle-shaped  opacity  ex- 
tending from  the  anterior  to  the  posterior  pole  of  the  lens. 
Central  cataract  is  a  small  speck  of  opacity  at  the 
center  of  the  lens.  Limited  specks  of  opacity  may  occur 
in  other  pirts  of  the  lens  and  remain  unchanged  through- 
out life. 

Diagnosis. — Partial  cataract  is  most  certainly  detected 
by  careful  search  with  the  ophthalmoscope.  The  exact 
location  of  the  opacity  is  to  be  determined  by  the  methods 
described  in  Chapter  IV  (see  page  81).  A  small  partial 
cataract  might  be  mistaken  for  a  foreign  body  in  the 
lens. 

Treatment. — Partial  cataract  is  serious  in  so  far  as  it 
obstructs  the  pupil.  Often  the  complete  dilatation  of  the 
pupil  produces  great  improvement  of  vision.  In  a  few 
of  these  cases  an  optical  iridectomy  enabling  the  patient  to 


422  PARTIAL  CATARACT. 

see  past  the  obstruction  will  be  beneficial ;  but  usually  if 
the  impairment  of  vision  justifies  operative  interference, 
it  is  best  to  remove  the  lens,  by  extraction  in  adults,  or 
discission  in  children.  The  loss  of  accommodation  by 
removal  of  the  lens  is  of  less  importance  in  these  cases, 
because  with  decided  lens-opacity,  the  accommodation  is 
usually  found  greatly  diminished.  Then,  too,  a  lens  with 
partial  opacity  is  especially  liable  to  complete  cataract  at 
a  later  period.  Even  opacity  confined  to  the  capsule,  or 
lying  on  the  normal  capsule,  as  the  exudate  in  occlusion 
of  the  pupil,  cannot  be  removed  without  removal  of  the 
whole  lens. 

Secondary  Cataract  (Capsular  Cataract  or  After- 
cataract). — The  common  operations  for  removal  of  cata- 
ract leave  a  part  or  the  whole  of  the  lens-capsule  in  the 
eye.  Operations  for  getting  rid  of  the  capsule  with  the 
lens  have  been  devised ;  but  their  difficulty  and  risk  are 
not  compensated  by  their  advantages.  Usually  the  cap- 
sule includes  the  remains  of  the  cortex  adherent  to  it. 
The  transparency  of  the  capsule  is  disturbed  by  the  ex- 
traction of  the  lens,  and  the  adherent  cortex  at  first  swells 
and  becomes  opaque ;  but  after  this  the  capsule  clears  up 
and  the  cortex  is  absorbed,  and  the  vision  improves  to  a 
maximum  a  few  weeks  or  months  after  the  extraction. 
Then  there  occurs  a  slow  process  of  thickening  of  the 
capsule,  which  causes  vision  to  deteriorate,  until,  commonly 
within  two  years,  it  has  fallen  a  good  deal  below  the 
maximum  attained  shortly  after  operation.  In  other 
cases,  as  after  the  extraction  of  an  unripe  cataract,  the 
cortex  left  behind  causes  an  opacity  that  entirely  obstructs 
the  pupil,  and  would  require  many  weeks  or  months  for 
its  absorption.  Or  after  the  extraction  of  a  hypermature 
or  complicated  cataract  the  capsule  is  so  decidedly  opaque 
as  to  seriously  impair  the  vision.  Again,  after  discission 
of  soft  cataract  there  often  remains  a  comparatively  thin, 
but  tough  opaque  mass,  which  tends  to  persist  indefinitely 
without  further  absorption  and  to  become  calcareous. 
These  are  all  included  under  the  heading  of  secondary 
cataract. 


DISEASES  OF  THE  CRYSTALLINE  LENS.         423 

Diagnosis. — With  the  ophthalmoscope,  if  the  obstruc- 
tion of  the  pupil  is  partial,  black  lines  or  masses  are  seen, 
which  are  found  to  be  in  the  plane  of  the  pupil ;  and  the 
details  of  the  fundus  are  found  to  be  indistinct.  The  oph- 
thalmoscopic  appearances  of  secondary  cataract  are  shown 
in  Fig.  132.  By  oblique  illumination  these  opacities 


FIG.  132.— Secondary  cataract.  Appearance  of  the  pupil  by  ophthalmoscopic 
illumination.  Two  iritic  adhesions.  The  capsule  clearer  in  upper  part  of  the 
pupil. 

appear  gray  or  brown.  When  the  obstruction  is  com- 
plete, the  pupil  is  seen  to  be  occupied  by  a  gray  or  white 
mass  resembling  a  mature  cataract ;  but  this  is  distin- 
guished from  primary  or  lenticular  cataract  by  the  great 
depth  of  the  anterior  chamber,  and  tremulousness  of  the 
iris,  showing  that  the  bulk  of  the  lens  has  been  removed ; 
and  by  history  of  the  previous  cataract  operation  of  some 
sort.  It  is  to  be  distinguished  from  opacity  in  the  an- 
terior vitreous  by  the  general  condition  of  the  eyeball. 
In  simple  secondary  cataract  the  tension  is  usually  normal 
or  not  much  diminished,  and  the  light-projection  and 
quantitative  perception  are  good.  But  vitreous  opacity, 
such  as  might  simulate  secondary  cataract,  is  often  at- 
tended with  decided  lowering  of  the  intra-ocular  tension, 
and  the  loss  of  light-projection  or  perception. 

Treatment. — Secondary  cataract  is  to  be  met  by  mak- 
ing a  sufficient  opening  through  it,  or  by  extracting  it 
from  the  eye.  The  former  operation  is  resorted  to  for 
comparatively  thin  membranes  that  can  be  readily  cut 
or  torn  through,  and  which  are  likely  to  retract  and  leave 
a  clear  opening  after  division.  The  removal  of  the 
opacity  is  indicated  when  it  is  comparatively  thick  and 
rigid,  and  especially  when  it  occupies  a  small  area  just 
behind  the  contracted  pupil.  The  operations  for  these 


424  SECONDARY  CATARACT. 

purposes  are  described  in  Chapter  XIX.  They  are  not 
without  danger.  They  may  cause  infection  of  the  eye,  and 
general  inflammation  of  the  uveal  tract. 

Dislocation  of  the  lens  (luxation  of  the  lens,  ectopia 
lentis)  occurs  sometimes  as  a  congenital  anomaly.  The 
lens  is  displaced  usually  upward,  but  sometimes  in  other 
directions.  The  displacement  is  commonly  symmetrical 
in  the  two  eyes,  but  may  be  confined  to  one.  The  edge 
of  the  lens  may  be  seen  in  the  pupil,  appearing  with  the 
ophthalmoscope  as  a  dark  line  on  the  red  background, 
distinguishable  from  anything  else  by  its  even  curve.  Its 
appearance  is  illustrated  in  Fig.  133.  Vision  is  commonly 


FIG.  133.— Congenital  dislocation  of  the  lens  upward  and  to  the  nasal  side  in 
the  left  eye.    Curved  lens-margin  seen  crossing  the  dilated  pupil. 

impaired  on  account  of  imperfect  focussing,  either  through 
the  edge  of  the  lens  where  the  eye  is  myopic,  or  outside 
the  lens  where  it  is  hyperopic.  Rarely  the  two  sets  of 
rays  cause  monocular  diplopia.  The  iris  is  pushed  for- 
ward on  the  side  toward  the  lens.  In  some  cases  the  lens 
seems  fixed  in  its  anomalous  position,  but  often  it  is 
movable.  In  a  few  cases,  the  patient  has  been  able  to 
swing  the  lenses  into  position  behind  the  pupil,  or  allow 
them  to  drop  away  by  changing  the  position  of  his  head 
and  eyes. 

The  discolated  lens  may  remain  perfectly  clear,  although 
it  generally  appears  a  faint  gray  by  oblique  illumination. 
If  entirely  loosened  from  its  normal  connections,  it  gradu- 
ally becomes  opaque. 

Occasionally  spontaneous  dislocation  of  the  lens  occurs 
through  relaxation  or  atrophy  of  its  suspensory  ligament. 
Often  it  only  amounts  to  a  partial  dislocation,  the  lens 
falling  back  at  one  part,  making  the  depth  of  the  anterior 
chamber  unequal  in  different  portions  and  at  different 


DISEASES  OF  THE  CRYSTALLINE  LENS.        425 

times.  In  other  cases  the  dislocation  is  complete,  the  lens 
falling  quite  away  from  the  pupil,  and  lying  usually  in 
the  lower  part  of  the  vitreous  chamber.  Such  a  freely 
movable  lens  is  liable  to  become  displaced  through  the 
pupil  into  the  anterior  chamber. 

When  dislocated  into  the  anterior  chamber,  the  clear 
lens  may  be  recognized  by  the  curved  line  of  brilliant 
reflex  from  its  edge.  If  opaque,  it  of  course  hides  the 
central  portion  of  the  iris,  and  is  distinguished  from  opa- 
city of  the  cornea  by  its  distinct  edge  and  greater  depth 
when  viewed  binocularly.  It  may  be  closely  simulated 
by  the  exudate  in  spongy  iritis.  A  dislocated  lens  if  at 
all  movable  is  a  constant  source  of  danger  in  the  eye.  It 
is  liable  to  cause  disorganization  and  opacity  of  the 
vitreous,  to  set  up  chronic  inflammation  of  the  uveal  tract, 
or  to  bring  on  glaucoma. 

Treatment. — Except  in  cases  where  the  lens  is  firmly 
fixed  in  its  abnormal  position,  and  does  not  interfere  with 
vision,  a  dislocated  lens  should  be  removed — by  discission 
and  absorption  in  young  eyes,  or  by  extraction  in  later 
life.  Sometimes  a  dislocated  lens  can  be  extracted  like 
an  ordinary  cataract,  sometimes  it  requires  the  use  of  a 
lens-spoon,  and  sometimes  a  two-pronged  fork  called  a 
bident,  or  a  straight  needle,  has  been  thurst  behind  it  to 
hold  it  forward  to  the  pupil,  in  position  for  extraction. 

Sometimes  a  lens  dislocated  into  the  anterior  chamber 
can  be  returned  behind  the  iris  (where  it  is  less  likely  to 
cause  immediate  harm)  by  dilating  the  pupil  fully  with 
homatropin,  and  manipulating  the  eyeball.  After  it  has 
thus  been  returned,  it  may  be  kept  behind  the  pupil  by 
the  instillation  of  eserin  (physostigmin)  solution  once  or 
twice  a  day. 

In  a  few  cases  of  traumatic  subltixation  the  lens  seems 
to  be  restored  to  its  normal  position  and  support  under 
long  rest  of  the  eye,  with  the  use  of  mydriatics.  Yet 
mydriatics  must  be  used  cautiously  when  the  lens  is  dis- 
located, on  account  of  the  possibility  of  their  increasing 
the  liability  to  glaucoma. 

Colobotna  of  the  lens  is  a  congenital  anomaly  in 


426  COLOBOMA    OF  THE  LENS. 

which  the  lens  appears  notched,  usually  at  its  lower  mar- 
gin.    It   is  rare,  and  mostly  associated  with   coloboma 


o 


FIG.  134.— Congenital  coloboma  of  the  lens  seen  through  coloboma  of  the  iris 
downward. 

of  the  iris  and  choroid,  as  in  the  case  illustrated  in  Fier. 
134. 

I^enticonus  is  a  rare  irregular  protrusion  of  one  of 
the  lens-surfaces,  usually  the  posterior,  causing  irregu- 
larity of  refraction  a  little  like  that  of  conical  cornea. 
It  may  be  studied  by  skiascopy  ;  and  by  shifting  the  point 
of  view,  the  irregular  refraction  is  seen  to  depend  on  the 
lens  rather  than  the  cornea. 

Aphakia,  or  complete  absence  of  the  lens,  may  occur 
as  a  congenital  anomaly.  But  most  of  the  cases  supposed 
to  be  of  this  class  are  really  cases  in  which  a  very  small 
lens  is  dislocated  so  as  to  be  invisible. 

Injuries  of  the  lens  are  considered  in  Chapter  XVII. 

DISEASES  OF  THE  VITREOUS. 

Vitreous  Opacities. — Impairment  of  transparency 
is  the  most  constant  symptom  of  disease  of  the  vitreous 
body.  It  is  a  symptom,  too,  that  is  prominent  in  many 
cases  of  diseases  of  the  choroid,  ciliary  body  and  retina, 
for  it  is  upon  the  vessels  of  these  parts  that  the  non- 
vascular  vitreous  depends  for  its  nutritive  supply. 

Symptoms  and  Varieties. — Vitreous  opacities  vary 
from  the  slightest  exaggeration  of  the  normal  specks  that 
can  be  perceived  subjectively  in  the  healthy  eye  (see  page 
42)  to  great  masses  that  render  the  eye  practically  blind. 
Opacities  of  much  importance  are  to  be  recognized  by 
the  ophthalmoscope,  although  some  too  small  to  be  visible 
do  cause  annoying  shadows,  especially  when  the  retina  is 
hyperesthetic  from  eye-strain. 


DISEASES  OF  THE  VITREOUS.  427 

Perfectly  diffuse  haziness  of  the  vitreous  sometimes 
occurs  in  connection  with  acute  hyalitis,  retinitis,  cyclitis, 
or  choroiditis.  Visible  opacities  have  the  forms  of  fine 
dust,  larger  flakes,  shreds  or  bands,  and  large  membranous 
masses.  They  are  illustrated  in  Fig.  135.  The  dust-like 
opacity  is  commonly  due  to  syphilitic  chorioretinitis  or 


FIG.  135. — Opacities  of  the  vitreous,  dust-like  at  lower  part  of  pupil,  with 
threads  and  membranous  masses  above. 

cyclitis.  The  flakes  and  shreds  are  formed  in  chronic 
choroidal  disease,  or  progressive  myopia  ;  the  large  float- 
ing membranous  masses  are  usually  the  remains  of  hemor- 
rhages into  the  vitreous.  Extensive  organized  mem- 
branes fixed  in  position  by  firm  attachment  to  the  retina 
are  supposed  to  have  developed  as  a  result  of  chronic 
retinal  disease,  and  are  spoken  of  as  retinitis  proliferans. 

Impairment  of  vision  from  retinal  opacities  varies  with 
their  density  and  situation.  Often  the  patient  can  by 
certain  movements  of  the  eyes  or  head  throw  an  obstruct- 
ing opacity  out  of  the  line  of  vision,  and  so,  for  an  instant, 
see  much  more  clearly.  In  other  cases  the  vision  grows 
better  when  the  eyes  are  for  some  time  kept  steady,  and 
the  floating  masses  allowed  to  settle  down. 

Diagnosis. — Subjectively  the  shadows  of  vitreous 
opacities  may  be  confused  with  scotomas  due  to  retinal 
or  choroidal  disease,  with  after-images  of  bright  lights, 
or  with  the  photopsias  of  disturbance  of  the  visual  centers. 
With  the  ophthalmoscope  the  opacities  may  be  mistaken 
for  pigment-masses  in  the  choroid,  or  opacities  in  the  lens 
or  cornea.  The  characteristic  of  the  vitreous  opacities  is 


428  VITREOUS   OPACITIES. 

their  peculiar  tremulous  movement  and  gradual  settling 
to  a  position  of  rest  after  any  movement  of  the  eyes. 
Their  usual  shapes  differ,  too,  quite  decidedly  from  those 
of  choroidal  pigment-patches  or  lens-opacities,  and  their 
depth  in  the  eye  as  measured  by  their  refraction  (see  page 
134)  or  parallax  (see  page  82)  indicates  their  character. 

Treatment. — This  must  be  chiefly  the  treatment  of  the 
cause  of  the  opacity,  or  the  disease  with  which  it  is  asso- 
ciated. When  no  other  ocular  lesion  is  discoverable,  any 
abnormality  of  the  general  health  should  be  attended  to. 
Alteratives,  especially  mercuric  chlorid  and  potassium 
iodid,  in  moderate  doses  long  continued,  may  be  quite 
beneficial.  Pilocarpin  sweats,  abstraction  of  blood  from 
the  temple,  and  local  applications  of  moderate  galvanic 
currents,  have  been  reported  beneficial.  Large  mem- 
branous opacities  may  sometimes  be  divided  with  a  narrow 
knife,  causing  vision  to  improve  and  the  opacity  to  shrink 
and  disappear.  This  should  not  be  attempted  until  many 
months  after  the  termination  of  the  disease  causing  the 
opacity. 

Prognosis. — The  smallest  vitreous  opacities,  those  that 
cause  the  muscce  volitantes  are  apt  to  occasion  the  greatest 
alarm.  Generally  the  patient  may  be  assured  that  they 
are  not  a  sign  of  danger.  But  the  prognosis  as  to  restora- 
tion of  the  transparency  of  the  vitreous  is  at  best  doubtful. 
Syphilitic  opacities  and  those  following  hemorrhages 
sometimes  clear  up  remarkably,  even  after  many  months ; 
those  attending  chronic  choroidal  disease  and  high  myopia 
generally  remain,  although  they  may  become  less  annoy- 
ing. 

Fluid  Vitreous  (Synchisis). — Undue  fluidity  of  the 
vitreous  is  only  recognized  by  the  unduly  free  movement 
of  opacities  in  it.  It  very  generally  occurs  with  exten- 
sive vitreous  opacities.  It  is  of  practical  importance  by 
indicating  degenerative  changes  in  the  eye,  and  by  com- 
plicating operations  for  cataract  or  glaucoma. 

Sparkling-  synchisis  (synchisis  scintittans)  is  the  name 
given  when  there  are  scattered  through  the  fluid  vitreous 
small  crystals  of  cholesterin,  tyrosin  and  phosphates, 


DISEASES  OF  THE  VITREOUS.  429 

which  are  seen  with  the  ophthalmoscope  to  glitter  and 
flash  as  they  move,  after  any  movement  of  the  eye.  This 
condition  is  usually  found  in  degenerated  eyes,  but  is  not 
incompatible  with  perfect  vision.  It  is  not  affected  by 
treatment. 

Hyalitis. — Inflammation  of  the  vitreous  arises  from 
inflammation  of  the  retina,  ciliary  body  or  choroid,  or 
by  infection  through  a  penetrating  wound,  or  foreign 
body.  It  is  marked  by  diffuse  opacity,  the  accumulation 
of  pus-cells  in  various  portions,  and  the  symptoms  of  the 
disease  with  which  it  is  associated.  It  tends  to  run  a 
chronic  course.  A  few  cases  partly  clear  up  ;  but  usually 
the  vitreous  comes  to  present  the  yellowish  mass,  called 
pseudo-glioma  (see  page  343),  sight  being  lost  and  the  ten- 
sion of  the  globe  permanently  diminished.  Rare  cases  of 
traumatic  hyalitis  make  complete  recoveries. 

Treatment. — Hyalitis  is  to  be  regarded  as  rather  a 
symptom  of  the  disease  causing  it,  to  wliich  the  treatment 
is  to  be  directed.  It  is  good  surgery  to  remove  a  sight- 
less eye  containing  a  collection  of  pus  in  the  vjtreous, 
even  though  there  be  no  chance  that  it  conceals  a  foreign 
body,  or  question  of  its  being  glioma  of  the  retina. 

Hemorrhage  into  the  vitreous  comes  from  the 
uveal  tract  or  retina,  and  is  due  to  traumatism,  vascular 
disease,  or  possibly  alteration  in  the  blood  itself.  Cases 
of  obscure  etiology  occur  in  early  adult  life.  It  causes 
dark  masses,  which  may  appear  red  on  the  margins. 
Vision  may  be  reduced  by  it  to  bare  light-perception,  or 
objects  seen  through  it  may  appear  red.  The  clot  is 
slowly  absorbed,  and  there  may  be  restoration  of  good 
vision,  but  generally  some  opacity  remains. 

Treatment. — At  the  time  of  the  hemorrhage,  rest, 
with  the  head  high,  cold  to  the  eye,  the  taking  of  blood 
from  the  temple,  and  cardiac  depressants,  may  be  em- 
ployed. Subsequently  careful  attention  to  the  general 
health,  with  pilocarpin  sweats,  and  small  doses  of  potas- 
sium iodid,  may  be  resorted  to.  Remaining  membranous 
opacities  may  be  cut  through  after  they  become  non- 


430  HEMORRHAGE  INTO  THE   VITREOUS. 

vascular,  and  all  tendency  to  inflammation  or  recurrence 
of  hemorrhage  appears  to  have  passed  away. 

Blood-vessels  in  the  vitreous  are  sometimes  formed 
after  the  occurrence  of  repeated  hemorrhages.  They 
arise  from  the  retinal  vessels,  pass  forward  into  the  vitre- 
ous in  the  form  of  net-work  of  small  vascular  loops, 
more  or  less  enveloped  in  opacity,  and  after  a  few  months 
or  longer  may  shrink  and  entirely  disappear.  A  mass  of 
such  vessels  is  illustrated  in  Fig.  136. 


FIG.  136.— New-formed  vessels  in  the  vitreous,  hiding  part  of  the  upper  tem- 
poral vessels  in  the  left  eye.  These  vessels,  being  in  advance  of  the  fundus, 
could  not  be  seen  distinctly  at  the  same  time  as  the  fundus,  as  represented  in 
the  picture. 

Detachment  of  the  vitreous  alone  is  not  clinically 
recognized  ;  but  it  attends  detachment  of  the  retina,  and 
shrinking  of  the  exudate  after  cyclitis. 

Parasites  in  the  Vitreous. — Filaria,  hydatids,  and 
cysticercus  have  Jbcen  found  in  this  situation.  In  North 
Germany  cysticercus  is  not  very  rare.  It  appears  while 
alive  as  a  round  bluish-white  cyst ;  from  which  extends 


DISEASES  OF  THE  VITREOUS.  431 

the  white  neck,  with  the  head  moving  slowly  back  and 
forth  independent  of  the  movements  of  the  eye.  After 
its  death  it  may  become  so  covered  with  lymph  as  to 
be  unrecognizable  with  the  ophthalmoscope.  If  the  para- 
site is  not  removed,  the  eye  is  liable  to  become  blind  and 
shrunken. 

Persistent  Hyaloid  Artery. — In  early  fetal  life  a 
branch  from  one  of  the  retinal  arteries  passes  forward 
from  the  optic  disk  to  the  posterior  pole  of  the  lens, 
where  it  breaks  up  into  many  minute  branches.  This 
vessel  is  called  the  hyaloid  artery.  Usually  it  atrophies 
before  birth,  but  in  a  few  cases,  some  traces  of  it  remain 
throughout  life,  and  in  a  very  few  it  continues  to  carry 
blood.  The  most  common  trace  of  it  is  a  speck  on  the 
posterior  capsule  of  the  lens ;  next  in  frequency  are  tags 
of  gray  tissue  on  the  optic  disk,  and  sometimes  a  wavy, 
gray  connective-tissue  chord  marks  its  course  through  the 
vitreous. 

BIBLIOGRAPHY. 

Incipient  Cataract.     A.  E.  Baker,  "Trans,  of  Sect,  on  Ophthalmol., 

Amer.  Med.  Assoc.,"   1895. 
Operative  Treatment  of  Immature  and   Zonular  Cataract.      J.  E. 

Weeks,  "  Trans,  of  Sect,  on  Ophthal.,  Amer.  Med.  Assoc.."  1895. 
Cataract  and  the  Gouty  and  Rheumatic  Diatheses.     S.  D.   Risley, 

"Trans.  Cong,  of  Amer.  Phys.  and  Surg.,"  1897. 
Glass-blower's   Cataract.       J.   Hirschberg,    "  Ophthalmic   Review," 

May,  1898. 
Limitation  and  Disappearance  of  Opacity  after  Injury.     E.  Jackson 

and  T.  B.  Schneideman,  "  Wills  Eye  Hosp.  Rep.,"  1895. 
Spontaneous  Absorption  of  Opacities  of  the   Lens.      H.   Schmidt- 

Rimpler,  "Ophthalmic  Review,"  Jan.,  1899. 
Ripening  of  Immature  Cataract  by  Direct  Trituration.    B.  Bettmann, 

"Trans.  Sect,  of  Ophtlial.,  Amer.  Med.  Assoc.,"  1893. 
Artificial  Ripening  of  Cataract.      Edward  Jackson,  "Trans.  Amer. 

Ophthalmol.  Soc.,"  1893. 
Operative  Treatment  of  Lamellar  Cataract.     E.  C.  Fisher  and  C.  D. 

Marshall,  "  Roy.  Lond.  Oph.  Hosp.  Rep.,"  vol.  xiv,  pt.  iii. 
Cataract  Operation.     E.  Laudolt,  "Ophthal.  Record/'  Oct.  and  Nov., 

1892;  "Ophthalmic  Review,"  Feb.,  1893. 

Simple  Extraction  of  Cataract.     H.  Kn;ipp,  "Trans.  Sect,  on  Oph- 
thalmol., Amer.  Med.  Assoc.,"  1892;  Eighth  Internal.  Ophthal- 
mol. Congress,  Edinburgh,  1893. 
Simple  Extraction  of  Cataract  Downward.    C.  Schweigger,  "Archives 

of  Ophthalmol.,"  May,  1898. 


432  BIBLIOGRAPHY. 

Preliminary  Iridectomy  in  the  Extraction  of  Senile  Cataract.    W.  F. 

Coleman,  "  Annals  of  Ophthahnol.,"  April,  1897. 
Cataract  Operations  and  Subsequent  Dressings.     J.  J.   Chisolm,  E. 

Jackson,  T.  E.  Murrell,  G.  E.  Frothingham,  "  Trans.  Sect,  on 

Ophthalmol.,  Amer.  Med.  Assoc.,"  1891. 

The  Open  Wound  Treatment  of  Eye  Operations.     J.  Hjort,  "Oph- 
thalmic Review,"  Mar.,  1898 ;  "  Amer.  Jour,  of  Ophthalmology," 

Dec.,  1898. 
!  emorrhage  Following  Cataract  Extraction.   J.  H.  Spalding,  "  Arch. 

of  Ophthalmol.,"  Jan.,  1896  ;  B.  E.   Fryer,  "  Amer.   Jour,  of 

Ophthalmol.,"   Feb.,   1899. 
Delayed  Union  After  Cataract  Extraction.     G.  C.  Harlan,  "  Trans. 

Amer.  Ophthalmol.  Soc.,"  1898. 
Operations  for  Secondary  Cataract.     H.  Knapp,  "Trans,  of  Amer. 

Ophthalmol.  Soc.,"  1898. 
Immediate   and   Remote   Results   of   Cataract   Extraction.      C.   D. 

Marshall,  "  Roy.  Lond.  Oph.  Hosp.  Rep.,"  vol.  xiv,  pt.  i. 
Lenticonus  Posterior.      W.  G.  Sym,  "  Ophthalmic  Review,"  Mar., 

1895. 
Ectopia  Lentis.     F.  B.  Tiffany,  "  Sect,  on  Ophthalmol.,  Amer.  Med. 

Assoc.,"  1895. 
Persistent  Remains  of  the  Fetal  Hyaloid  Artery  ;  80  pages.     D.  De 

Beck,  Cincinnati.,  "Ophthalmic  Review,"  May,  1891. 
Diseases  of  the  Vitreous.   Flemming  Carrow,  "  American  Text-book." 
Vitreous  Opacity  from  Exceptional  Causes.     Jonathan  Hutchinson, 

"Ophthalmic  Review,"  Jan.,  1889. 
Surgical  Treatment  of  Vitreous  Opacities.     C.  S.  Bull,  "  Ophthalmic 

Review,"  June,  1890. 


CHAPTER    XV. 

DISORDERS  OF  TENSION  OF  THE  EYEBALL. 

Normal  Intra-ocular  Currents  and  Pressure. — 

The  preservation  of  the  shape  of  the  eyeball,  the  curva- 
ture of  the  cornea,  and  the  normal  relation  of  the  dioptric 
surfaces  to  the  retina  depend  on  the  intra-ocular  tension. 
The  sclerocorneal  coat  is  a  closed  sac  fitted  to  resist  in- 
ternal pressure.  Its  contents,  pressing  outward  at  every 
point,  keep  it  distended,  against  the  external  pressure  of 
the  lids,  extra-ocular  muscles,  and  orbital  tissues.  This 
normal  intra-ocular  tension  equals  the  pressure  of  a 


DISORDERS  OF  OCULAR   TENSION.  433 

column  of  mercury  25  to  30  mm.  (1—1.2  inches)  in  height. 
It  varies  somewhat  within  the  limits  of  health,  and  may 
vary  in  disease  from  nothing  to  the  equivalent  of  200 
mm.  (8  inches)  of  mercury  or  more. 

The  cornea,  crystalline,  and  vitreous  humor  are  non- 
vascular,  and  are  nourished  by  fluid  from  the  capillaries 
of  other  tissues.  The  supply  of  this  fluid  must  be  kept 
up  continuously,  or  the  nutrition  of  these  parts  of  the  eye 
would  suffer.  This  fluid,  constantly  poured  into  the  eye, 
must  as  constantly  escape  from  it,  or  undue  distention  of 
the  eyeball  and  increased  intra-ocular  tension  result.  In- 
creased inflow  must  be  balanced  by  a  free  passage  through 
the  channels  of  escape.  This  suggests  the  existence  of  a 
mechanism  co-ordinating  inflow  and  outflow.  But  of  the 
portion  of  the  nervous  system  for  the  regulation  of  intra- 
ocular tension  we  know  little. 

The  inflow  of  fluid  comes  through  the  cornea  from  the 
vessels  of  the  peri  corn  eal  zone,  from  the  choroid,  and 
particularly  from  the  vessels  of  the  ciliary  processes. 
From  the  latter  sources  the  fluid  passes  through  the 
vitreous  body  around  the  crystalline  lens,  forward  through 
the  pupil.  The  principal  escape  of  fluid  from  the  eye 
occurs  at  the  angle  of  the  anterior  chamber,  where  the 
cornea  is  devoid  of  epithelium,  and  large  lymph-spaces 
connect  the  anterior  chamber  with  the  canal  of  Schlemm, 


FIG.  137.— Path  of  intra-ocular  fluids. 


a  large  drainage-channel  within  the  sclera.    The  path  of 
the  intra-ocular  fluid  is  illustrated  in  Fig.  137. 

Diminished  intra-ocular  tension  may  arise  from  dimin- 
ished inflow  or  increased    outflow  :    or  increased  tension 


28 


434  INTRA-OCULAR   TENSION. 

from  increased  inflow  or  diminished  outflow.  Of  these 
possible  conditions  most  is  known  about  diminished  inflow, 
causing  lowered  tension  ;  and  diminished  outflow,  causing 
increased  tension. 

Intra-ocular  tension  is  tested  by  placing  the  tips 
of  two  fingers,  usually  the  two  fore-fingers,  either  on  the 
upper  lid  above  the  cartilage  when  the  lids  are  lightly 
closed  and  the  eye  rolled  down,  or  upon  the  sclera  below 
the  cornea  when  the  eye  is  rolled  up.  Making  pressure 
with  one  finger  while  the  other  steadies  the  eyeball,  the 
amount  of  pressure  required  to  dimple  or  press  in  the  sur- 
face of  the  eye  is  a  measure  of  the  intra-ocular  tension. 

Care  must  be  observed  that  a  rigid  sclera  is  not  mis- 
taken for  increased  tension.  The  best  guide  as  to  change 
of  tension  is  comparison  of  the  resistance  of  the  eye 
under  examination  with  that  of  a  normal  eye, — either  the 
patient's  other  eye  if  normal,  the  surgeon's  eye,  or  that  of 
some  third  person.  Allowance  must  be  made  for  individual 
peculiarities  and  increasing  rigidity  of  the  sclera  with 
increasing  age. 

By  this  method  very  exact  knowledge  of  the  changes 
of  intra-ocular  tension  cannot  be  attained,  and  the  common 
plan  of  indicating  such  changes  is  probably  as  exact  as 
could  be  practically  useful.  This  plan,  suggested  by 
Bowman,  is : 

Normal  tension, T  n 

Slight,  but  distinct,  increase  of  tension, +  T  1 

Very  marked  increase  of  tension, +  T  2 

Greatest  increase  of  tension, +T3 

Slight,  but  distinct,  decrease  of  tension, —  T 1 

Very  marked  decrease  of  tension, —  T  2 

Eyeball  perfectly  soft  and  unresisting, —  T  3 

Sometimes  +  T  ?  and  —  T  ?  are  used  to  indicate  a 
doubtful  increase  or  decrease. 

GLAUCOMA. 

Glaucoma  is  increased  intra-ocular  tension,  with  the 
causes  and  results  of  such  increase.  The  word  originally, 
in  the  ancient  Greek,  referred  only  to  the  reflex  of  light 


DISORDERS  OF  OCULAR   TENSION.  435 

in  the  pupil,  including,  among  other  conditions,  cataract. 
But  as  other  conditions  have  been  classed  under  other 
titles  it  has  gradually  come  to  include  only  the  disease 
causing  blindness  with  increased  tension  of  the  eyeball. 

Primary  glaucoma  includes  all  cases  of  increased 
intra-ocular  tension  not  preceded  by  injury  or  other 
marked  disease  of  the  eyeball.  It  includes  glaucoma 
with  exacerbations,  and  simple  glaucoma.  Secondary 
glaucoma  includes  several  forms  of  diverse  origin,  but 
with  the  common  tendency  to  blindness  with  high 
tension. 

Glaucoma  with  exacerbations  (inflammatory  glau- 
coma, acute  and  chronic)  is  marked  by  a  sudden  appear- 
ance or  sudden  increase  of  its  symptoms,  which  subse- 
quently remit  or  intermit,  but  again  recur.  The  recurring 
exacerbations  gradually  become  more  severe,  each  time 
leaving  the  eye  damaged  to  a  greater  extent,  and  finally 
they  end  in  complete  blindness,  with  great  pain. 

Symptoms  and  Course. — Early  loss  of  the  power  of 
accommodation,  increasing  hyperopia  and  the  appearance 
or  increase  of  astigmatism  against  the  rule,  are  thought 
to  indicate  the  probability  of  glaucoma  (incipient  glau- 
coma). Frequent  changes  in  the  amount  or  direction  of 
the  astigmatism,  or  inability  to  use  the  eyes  to  a  normal 
extent  without  obvious  reason  for  it,  have  the  same  sig- 
nificance. But  these  symptoms  cannot  be  regarded  as 
surely  symptoms  of  glaucoma,  since  they  all  occur  in 
eyes  that  never  show  any  tendency  to  increased  tension. 

The  first  positive  symptom  to  attract  attention  is 
usually  disturbance  of  vision.  The  vision  in  one  or  both 
eyes  is  temporarily  blurred,  or  a  ring  or  halo  is  noticed 
around  the  lamp-flame  at  night.  This  halo  is  10  degrees 
or  12  degrees  in  diameter  and  exhibits  the  colors  of  the 
rainbow,  with  the  violet  inward,  the  red  outward.  Like 
the  dimness  of  vision,  it  is  at  first  entirely  intermittent, 
is  seen  when  the  patient  is  tired  or  indisposed,  and  after 
a  good  night's  rest,  disappears.  At  the  periods  of  im- 
paired vision,  the  pupil  is  somewhat  dilated,  although  at 
other  times  still  of  normal  size.  Close  examination  will 


436  GLAUCOMA    WITH  EXACERBATIONS. 

show  that  the  anterior  chamber  is  shallow,  especially 
toward  its  periphery. 

The  obscurations  of  vision  recur,  become  greater,  last 
longer,  are  attended  with  more  marked  dilatation  of  the 
pupil,  and  subsequently  with  pain.  They  also  become 
marked  by  redness  of  the  pericorneal  zone,  and  distinct 
attacks  of  acute  inflammation,  attended  with  general 
cloudiness  of  the  cornea,  and  consequent  alteration  of  the 
appearance  of  the  iris,  and  blurring  of  the  ophthalmo- 
scopic  image.  Examination  will  now  show  that  the  field 
of  vision  is  becoming  impaired,  and  probably  the  acute- 
ness  of  vision  at  the  fovea  will  remain  below  normal 
between  the  attacks.  With  the  progressive  impairment 
of  central  vision  and  the  narrowing  of  the  visual  field  the 
halo  symptom  becomes  less  noticeable  or  disappears 
altogether. 

If  the  case  be  not  efficiently  treated,  the  exacerbations 
become  more  frequent  and  severe,  the  remissions  less 
complete.  The  permanent  alteration  of  the  field  and  of 
central  vision  become  greater,  until  blindness,  constant 
pain  and  continuous  inflammation  are  established  (abso- 
lute glaucoma}.  After  a  variable  period  of  pain  and  in- 
flammation these  may  subside,  leaving  a  sightless  but 
painless  eyeball ;  or  the  intra-ocular  tension  may  cause 
staphyloma  and  rupture,  with  partial  escape  of  the  con- 
tents of  the  globe,  succeeded  sometimes  by  panophthal- 
mitis. 

If  not  checked  by  treatment,  the  course  of  the  disease 
is  always  to  complete  and  irremediable  blindness.  In 
rare  cases  this  results  from  the  first  outbreak  noticed,  or 
through  one  violent  outbreak  preceded  by  only  a  few 
insignificant  exacerbations  (glaucoma  fuhnmans).  In  rare 
cases,  after  one  or  two  exacerbations,  the  eye  remains  free 
from  them  for  some  time,  or  the  excerbations  occur  at 
long  intervals  and  increase  but  little  in  severity. 

Corneal  Anesthesia. — At  first,  during  the  exacerbations, 
and  later  continuously,  the  cornea  becomes  comparatively 
insensitive  to  touch  ;  and  we  have  an  exquisitively  pain- 


DISORDERS  OF  OCULAR  TENSION.  437 

ful  eye  showing  less  reaction  when  lightly  touched  on  the 
cornea  than  the  normal  fellow  eye. 

Pain  always  attends  glaucoma  with  exacerbations,  and 
usually  in  the  later  stages  is  extremely  severe.  The 
writer  has  known  a  patient  to  lose  fifty  pounds  weight  in 
six  weeks,  through  the  suffering  from  glaucoma.  The 
pain  is  not  relieved  by  drugs  or  by  any  form  of  local 
treatment,  except  such  as  diminishes  the  intra-ocular 
tension. 

The  impairment  of  the  field  of  vision  begins  commonly 
in  the  periphery,  is  usually  greater  on  the  nasal  side,  and 
is  apt  to  be  permanent.  Fig.  138  shows  a  common  form 


FIG.  138.— Field  of  vision  in  glaucoma. 

of  limitation ;  but  the  form  may  vary  greatly.  In  some 
cases  the  outline  of  the  field  becomes  very  irregular,  often 
scotomas  may  be  found.  Central  vision  is  sometimes  lost 
while  some  eccentric  vision  is  still  retained,  but  ultimately 
all  perception  of  light  is  lost. 

The  ophthalmoscopic  symptoms  include  the  appearances 
produced  by  pressure.  The  most  striking  is  cupping  of 
the  optic  nerve  (see  Plate  II,  6,  and  Fig.  32,  p.  97).  The 
increased  tension  also  causes  collapse  of  the  arteries  in  the 
interval  between  the  pulse- waves,  giving  rise  to  arterial 
pulsation.  This  may  be  seen  either  at  the  margin  of  the 
cup,  or  where  the  vessels  appear  on  its  floor.  Pulsation 
of  the  veins  in  this  situation  is  normal  in  many  eyes. 
Arterial  pulsation  is  one  of  the  first  symptoms  of  increased 
intra-ocular  tension.  But  it  is  often  difficult  to  detect, 


438 


SYMPTOMS  OF  GLAUCOMA. 


and  may  be  temporarily  abolished  by  previous  pressure 
on  the  eyeball,  as  in  testing  intra-ocular  tension.  The 
formation  of  a  glaucoma-cup  requires  time.  During  the 
early  exacerbations,  no  sign  of  it  will  be  detected.  When 
formed,  however,  it  is  permanent,  and  is  usually  the  most 
positive  sign  of  glaucoma  to  be  found  between  the  exacer- 
bations. In  chronic  glaucoma  the  optic  disk  is  usually 
surrounded  by  a  comparatively  uniform  ring  or  halo  of 


FIG.  139.— Fundus  in  chronic  glaucoma.  Disk  deeply  cupped  to  its  extreme 
margin,  and  surrounded  by  a  white  ring  or  "  halo "  of  choroidal  atrophy. 
Vessels  disappear  on  sides  of  the  glaucoma-cup. 

choroidal  atrophy.     The  ophthalmoscopic  symptoms  of 
glaucoma  are  illustrated  in  Fig.  139. 

Causes  and  Pathology. — On  the  average,  out  of  ten 
cases  of  glaucoma  six  occur  in  women  and  four  in  men. 
Jews  are  particularly  liable  to  it.  Negroes  suifer  from  it 
but  rarely.  The  liability  is  hereditary  in  certain  families  ; 
and  it  increases  with  age  up  to  seventy,  and  after  that 
declines.  It  is  rare  before  the  age  of  forty.  Still,  sev- 


DISORDERS  OF  OCULAR  TENSION.  439 

eral  cases  have  been  reported  occurring  before  the  age  of 
twenty.  An  exacerbation  may  be  excited  by  grief,  mental 
shock,  worry,  exhaustion,  and  especially  by  dilatation  of 
the  pupil  with  a  mydriatic. 

Examination  of  eyes  removed  for  absolute  glaucoma, 
the  clinical  history  of  the  disease,  and  the  influences  of 
treatment,  all  indicate  that  a  very  important  factor  in 
causing  increased  tension  in  the  eyeball,  is  blocking  of 
the  outflow  from  the  anterior  chamber.  Eyes  blind  with 
this  disease  show  the  periphery  of  the  iris  permanently 
adherent  to  the  posterior  surface  of  the  cornea,  the  lymph- 
channels  being  entirely  closed.  This  condition  is  illus- 
trated in  Fig.  141,  in  contrast  with  the  normal  condition 


FIG.  140.  FIG.  141. 

Angle  of  the  anterior  chamber :  Fig.  140,  in  the  normal  eye ;  Fig.  141,  in  a 
glaucomatous  eye. 

shown  in  Fig.  140.  The  action  of  mydriatics  also  illus- 
trates the  influence  of  blocking  the  angle  of  the  anterior 
chamber.  The  dilatation  of  the  pupil  causes  thickening 
of  the  periphery  of  the  iris,  thus  closing  for  the  time  the 
outflow  channels.  Cocain,  while  dilating  the  pupil,  so 
contracts  the  blood-vessels  as  to  prevent  thickening  of  the 
iris  periphery ;  and  it  does  not  show  the  same  tendency 
to  produce  an  outbreak. 

The  conditions  which  bring  about  secondary  glaucoma 
also  act  the  same  way.  Dislocation  or  swelling  of  the 
lens  pushes  the  periphery  of  the  iris  forward.  Occlusion 
of  the  pupil,  causing  iris  bombe,  does  the  same  thing. 
Eserin  (physostigmin)  by  contracting  the  pupil,  thins  the 
periphery  of  the  iris  and  draws  it  away  from  the  cornea, 
thus  reopening  the  outflow  channels. 

Priestley  Smith  has  shown  thatthe  predisposing  influence 


440  PATHOLOGY  OF  GLAUCOMA. 

of  age  is  also  thus  explained  :  The  crystalline  lens,  like 
other  epithelial  structures,  continues  to  grow  throughout 
life,  at  least  until  sixty  or  seventy  years  of  age,  when  it 
may  begin  to  degenerate  and  shrink ;  the  enlarged  lens 
pressing  on  the  ciliary  processes,  and  through  them  pushing 
forward  the  periphery  of  the  iris,  predisposes  to  the 
blocking  of  the  angle  of  the  anterior  chamber.  He  also 
points  out  that  eyes  having  a  comparatively  small  cornea, 
and  therefore  less  space  between  the  lens  and  the  ciliary 
processes  are  more  liable  to  glaucoma.  Glaucoma  may 
be  associated  with  rheumatism,  gout,  vascular  disease,  and 
disturbances  of  circulation.  Eye-strain  has  been  regarded 
as  a  factor. 

Diagnosis. — Glaucoma  is  characterized  by  increased 
intra-ocular  tension  ;  but  a  slight  increase  cannot  be  recog- 
nized with  certainty ;  and  even  in  glaucoma  of  long  stand- 
ing, the  tension  may  much  of  the  time  be  normal.  The 
history  of  repeated  attacks  or  relapses  is  very  suggestive, 
and  cupping  of  the  disk,  with  impairment  of  the  field  of 
vision  is  quite  characteristic.  Dilatation  of  the  pupil, 
shallowness  of  the  anterior  chamber,  and  dilatation  of  the 
scleral  veins,  are  also  important  symptoms. 

When  the  premonitory  symptoms  of  glaucoma  are 
present,  but  a  positive  diagnosis  cannot  be  made,  the  in- 
stillation of  homatropin  or  euphthalmin  will  probably  cause 
arterial  pulsation  and  other  signs  of  increased  tension,  if 
glaucoma  is  really  imminent.  This  is  a  proper  diagnostic 
procedure,  provided  its  character  is  explained  to  the  pa- 
tient, and  his  assent  obtained  to  the  prompt  treatment  of 
the  disease,  if  thus  rendered  manifest. 

Glaucomatous  attacks  are  sometimes  mistaken  for 
neuralgia,  the  severe  pain  being  referred  to  the  brow  and 
cheek  rather  than  to  the  eye.  Such  an  error  can  always 
be  avoided  by  examining  the  tension  of  the  eye,  the  field 
of  vision,  the  size  of  the  pupil,  and  the  appearance  of  the 
optic  disk. 

The  haziness  of  the  cornea  with  pericorneal  redness 
may  cause  it  to  be  confused  with  keratiti* ;  but  with  these 
symptoms  the  tension  is  always  raised,  and  the  pupil 


DISORDERS  OF  OCULAR   TENSION.  441 

somewhat  dilated  in  glaucoma,  while  in  keratitis  the  ten- 
sion would  be  normal  and  the  pupil  rather  contracted. 
Sometimes  glaucoma  has  been  mistaken  for  erysipelas.  It 
lacks  the  tense  red  skin ;  and  erysipelas  does  not  present 
the  changes  of  the  eyeball  that  mark  glaucoma.  It 
should  be  remembered  that  acute  glaucoma  sometimes 
follows  or  complicates  facial  erysipelas. 

Iritis  resembles  an  exacerbation  of  glaucoma  in  pain, 
photophobia,  impaired  vision,  and  pericorneal  redness; 
but  in  iritis  the  pupil  is  contracted  instead  of  dilated, 
and  often  bound  down  by  posterior  synechise.  Oyclitis 
still  more  closely  resembles  glaucoma,  for,  in  cyclitis,  the 
pupil  may  be  widely  dilated  by  a  mydriatic,  and  slight 
increase  of  tension  may  occur.  The  existence  of  deposits 
on  the  posterior  surface  of  the  cornea,  or  the  age  and  his- 
tory of  the  patient,  or  the  integrity  of  the  field  of  vision, 
may  decide  the  diagnosis.  In  doubtful  cases  it  will  be 
better  to  avoid  a  mydriatic  until  observation  of  the  case 
has  settled  the  diagnosis.  The  inflammatory  exacerba- 
tions of  glaucoma  are  generally  accompanied  by  markedly 
high  tension.  Other  points  as  to  the  diagnosis  are  con- 
sidered with  simple  glaucoma. 

Treatment. — The  chief  remedy  for  glaucoma  is  a  large 
iridectomy  (see  Chapter  XIX).  This  is  curative  in  the 
sense  that  in  most  cases  of  glaucoma  with  exacerbations 
the  increase  of  tension  is  permanently  relieved,  and 
further  pain  and  inflammatory  attacks  prevented.  But 
the  eye  is  not  restored  to  its  original  condition ;  hence, 
the  earlier  the  iridectomy  is  done,  the  better  the  result. 

Sclerotomy  (Chapter  XIX)  and  radial  incision  of  the 
ciliary  body  are  also  done  to  relieve  glaucoma.  They 
should  not  be  depended  upon  for  eyes  in  which  there  is  a 
reasonable  chance  of  saving  useful  vision  by  iridectomy. 
Stretching  the  nasal  branch  of  the  ophthalmic  division  of 
the  fifth  nerve  has  been  practised  on  theoretical  grounds, 
but  is  of  doubtful  value.  Jonnesco  and  Abadie  have 
recently  urged  and  practiced  excision  of  the  cervical  sympa- 
thetic. In  operating  on  one  eye,  it  is  generally  well  to 
instil  a  myotic  in  the  other,  since  the  excitement  and 


442  TREATMENT  OF  GLAUCOMA. 

shock  of  operation  sometimes  provoke  an  outbreak  in  the 
second  eye. 

In  commencing  or  suspected  glaucoma  the  careful  cor- 
rection of  errors  of  refraction  may  be  beneficial.  After 
iridectomy  there  usually  remains  an  increased  astigmatism 
against  the  rule,  which  must  be  corrected  to  give  the  best 
vision. 

In  the  earlier  stages,  while  the  pupil  can  still  be  con- 
tracted by  them,  the  instillation  of  the  myotics,  eserin, 
(physostigmin,)  and  pilocarpin  have  a  marked  influence 
in  relieving  and  preventing  exacerbations.  This  influence 
is  enhanced  by  combination  with  cocain,  which  tends  to 
lower  the  intra-ocular  tension  as  well  as  contract  the  iris. 
In  a  few  cases  the  use  of  these  drugs  has  been  followed 
by  no  return  of  increased  tension.  But  they  should  be 
regarded  only  as  palliative.  In  most  cases  the  myotic 
when  used  for  a  time  gradually  loses  its  beneficial  in- 
fluence until  it  becomes  quite  powerless;  and  meamvhile 
great  and  irremediable  damage  may  be  done  to  the  eye. 
Mydriatics  (except  as  indicated  on  page  440)  are  to  be 
carefully  avoided  in  primary  glaucoma. 

Care  should  be  taken  to  avoid  indigestion,  worry,  over- 
work, loss  of  sleep,  and  congestion  of  the  head  from  stoop- 
ing, which  may  precipitate  an  attack.  The  use  of  natural 
mineral  waters  and  other  means  of  increasing  elimination 
are  beneficial.  Sometimes  an  attack  can  be  relieved  by  a 
hot  bath,  morphin  internally,  sleep,  or  a  moderate  cathar- 
sis. Gentle  massage  of  the  eyeball  through  the  closed 
lids  tends  to  reduce  the  tension.  When  sight  is  gone  and 
pain  continues,  enucleation  of  the  eye  is  the  only  thing 
certain  to  give  relief. 

Prognosis. — Glaucoma  left  to  itself  causes  blindness, 
and  usually  great  pain  ;  and  when  well-marked  exacerba- 
tions have  occurred,  there  is  little  prospect  of  farther  use- 
fulness of  the  eye  except  through  operative  treatment. 
In  a  few  cases  moderate  attacks  of  glaucoma  occur  at 
intervals  for  several  years  before  much  permanent  impair- 
ment of  vision  or  other  damage  results. 

Early  iridectomy,  while  the  pupil  is  still  mobile,  the 


DISORDERS  OF  OCULAR  TENSION.  443 

fields  of  vision  not  much  contracted,  and  the  cupping  of 
the  disk  slight,  commonly  cures  glaucoma,  preserves  what 
sight  remains,  and  may  restore  what  has  been  lost  within 
a  few  days.  In  a  few  cases  the  repetition  of  iridectomy 
cures  when  the  first  operation  has  failed  to  do  so.  Iri- 
dectomy done  late  in  the  disease  is  less  sure  to  check  it. 
When  the  field  of  vision  is  encroached  upon  to  near  the 
point  of  fixation,  iridectomy  may  be  followed  by  loss  of 
central  vision.  Or  the  operation  may  cause  temporary 
blindness  by  blood  left  in  the  anterior  chamber,  or  hemor- 
rhage from  the  choroid.  In  a  few  cases,  operation  is  fol- 
lowed in  a  few  hours  or  days  by  a  violent  return  of  high 
tension,  great  pain  and  inflammation,  (malignant  glaucoma), 
for  which  the  eye  has  to  be  enucleated.  Glaucoma  usu- 
ally attacks  both  eyes,  but  occasionally  the  second  eye 
altogether  escapes. 

Simple  glaucoma  (chronic  primary  glaucoma)-  is  a 
disease  in  many  respects  essentially  distinct  from  glau- 
coma with  exacerbations.  The  increase  of  tension  is  at 
first  slight,  and  very  gradual.  The  anterior  chamber  is 
not  especially  shallow,  the  pupil  is  not  dilated,  there  are 
no  inflammatory  exacerbations.  The  field  of  vision  may 
be  greatly  contracted  before  central  vision  is  notably  im- 
paired. There  is  no  clouding,  and  no  marked  anesthesia 
of  the  cornea  until  late  in  the  disease. 

Causes  and  Pathology. — These  are  probably  essen- 
tially different  from  those  of  other  forms  of  glaucoma. 
There  is  little  evidence  of  obstruction  of  the  angle  of  the 
anterior  chamber,  although  there  may  be  closure  of  the 
lymph-channels  that  connect  it  with  the  canal  of  Schlemm, 
by  connective-tissue  hyperplasia.  In  some  cases,  high 
tension  cannot  be  demonstrated  until  after  the  disk  has  be- 
come deeply  cupped,  or  the  eye  quite  blind.  In  a  few  cases, 
otherwise  like  glaucoma,  no  positive  increase  of  tension 
can  be  detected  at  any  time.  Yet  these  cases  differ  from 
simple  optic  atrophy  in  having  a  distinct  glaucoma-cup. 
It  is  this  form  of  glaucoma  that  is  probably  most  closely 
connected  with  gout,  rheumatism,  general  angiosclerosis, 
and  chronic  nerve-exhaustion. 


444  SIMPLE  GLAUCOMA. 

Diagnosis. — The  patient  is  over  fifty  years  of  age,  and 
both  eyes  are  usually  affected,  though  often  one  consider- 
ably earlier  or  more  than  the  other.  The  glaucoma-cup 
and  narrowing  of  the  field  of  vision  are  always  present, 
and  tension  is  usually  increased.  Upon  these  symptoms 
and  the  absence  of  others  the  diagnosis  must  rest.  This 
is  the  form  of  glaucoma  most  likely  to  be  mistaken  for 
cataract. 

Prognosis  and.  Treatment. — Simple  glaucoma  runs  a 
chronic  course,  usually  lasting  several  years  before  blind- 
ness is  complete ;  and  often  it  is  not  attended  by  severe 
pain.  It  is  also  less  curable  by  iridectomy  than  glau- 
coma with  exacerbations,  and  sometimes  does  badly  after 
that  operation.  One  cannot,  therefore,  urge  it  as  in  other 
forms  of  glaucoma.  Still,  iridectomy  done  early  oifers 
the  best  prospect  of  permanent  arrest  of  the  process. 

If  the  patient  declines  to  have  an  iridectomy  done,  the 
regular  instillation  of  eserin  (physostigmin)  seems,  some- 
times, to  delay  the  loss  of  vision.  The  internal  use  of 
alteratives  and  strychnin  may  be  of  benefit.  Careful 
treatment  of  a  gouty  or  rheumatic  diathesis  may  also  be 
important. 

Secondary  glaucoma  includes  all  cases  in  which 
increased  intra-ocular  tension  arises  in  consequence  of 
other  serious  lesions  of  the  eye. 

Hemorrhagic  Glaucoma. — In  a  few  cases,  after 
numerous  retinal  hemorrhages,  glaucoma  supervenes. 
Often  several  months  elapse  between  the  appearance  of 
the  first  hemorrhage  and  the  rise  of  intra-ocular  tension. 
After  the  glaucoma  sets  in,  the  course  and  symptoms  are 
essentially  those  of  an  acute  glaucoma  with  exacerbations. 
The  prognosis  is  very  bad.  Vision  is  impaired  to  start 
with.  Iridectomy  usually  fails  to  check  the  course  of  the 
disease,  and  eserin  is  commonly  ineffective.  A  large  pro- 
portion of  cases  are  only  relieved  of  pain  by  enucleation. 
The  second  eye  mostly  escapes,  but  often  the  patient  dies 
in  a  few  years  of  cerebral  hemorrhage  or  other  vascular 
disease.  Still,  iridectomy  may  save  the  eye,  and,  if  the 
patient  so  desires,  should  be  tried  as  a  forlorn  hope. 


DISORDERS  OF  OCULAR  TENSION.  445 

Post-iritic  Glaucoma. — The  effect  of  annular  synechia, 
exclusion  of  the  pupil,  in  damming  back  the  fluid  which 
should  normally  pass  forward  through  the  pupil,  causing 
ballooning  of  the  iris,  and  thus,  obstruction  of  the  anterior 
chamber,  has  already  been  explained  (page  328).  In  other 
cases,  iritic  inflammation  seems  to  extend  to  the  angle  of 
the  anterior  chamber,  and  by  cicatricial  contraction  to 
cause  its  closure.  Eyes  that  have  'suffered  from  chronic 
syphilitic  inflammation  of  the  uveal  tract  are  liable  thus 
to  develop  glaucoma. 

For  exclusion  of  the  pupil,  a  moderate  iridectomy  done 
early  and  so  situated  as  to  give  the  best  optical  effect, 
may  prevent  further  mischief.  For  cases  in  which  glau- 
coma follows  iritis  without  exclusion  of  the  pupil,  the 
regular  glaucoma  iridectomy  should  be  done,  great  care 
being  taken  to  remove  a  large  part  of  the  ciliary  border 
of  the  iris.  In  post-iritic  glaucoma,  mydriatics  may 
sometimes  be  used  without  danger,  and  with  advantage. 
When  the  iris  is  extensively  bound  to  the  lens-capsule  by 
adhesions,  there  is  little  danger  of  mydriatics'  doing  serious 
harm  in  the  glaucomatous  eye. 

Glaucoma  with  Intra-ocular  Growths. — Sarcoma  of 
the  choroid  and  glioma  of  the  retina,  at  a  certain  stage  of 
their  growth,  cause  increased  tension  with  the  general 
symptoms  of  acute  glaucoma  with  exacerbations.  The 
pain  and  obvious  inflammation  of  this  stage,  with  loss  of 
sight,  which  rapidly  becomes  complete,  and  the  prospect 
of  no  other  relief,  often  induce  the  patient  to  submit  to 
the  only  efficient  treatment,  the  removal  of  the  eye. 

Glaucoma  Following  Traumatism. — Injuries  cans-  • 
ing  dislocation  or  much  swelling  of  the  crystalline  lens 
are  generally  followed  by  glaucoma ;  even  where  no  dis- 
turbance of  the  lens  has  been  noticed,  glaucoma  has 
sometimes  followed.  Dislocation  of  the  lens  into  the 
anterior  chamber  is  usually  followed  by  a  prompt  rise  of 
intra-ocular  pressure.  Swelling  of  the  lens,  always  ac- 
companied by  opacity,  or  complete  luxation,  or  decided 
loosening  of  the  lens  from  its  normal  attachments,  should 
be  met  by  its  prompt  removal.  Slighter  displacements 


446  SECONDARY  GLAUCOMA. 

may  be  treated  by  rest  with  instillation  of  physostigmin,  or 
a  mydriatic,  or  by  a  glaucoma  iridectomy. 

Glaucoma  from  adherent  leukoma  arises  when  the 
leukoma  tends  to  extend  and  to  drag  the  iris  into  closer 
contact  with  the  cornea,  and  become  a  staphyloma.  The 
tension  does  not  usually  get  very  high,  because  the  staphy- 
loma yields  before  it.  The  treatment  is  that  given  for 
anterior  staphyloma.* 

Buphthalmos  (hydrophthalmos,  glaucoma  of  childhood) 
depends  on  a  congenital  failure  of  the  angle  of  the  an- 
terior chamber  to  open  as  it  does  in  the  course  of  normal 
development.  This  causes  increased  tension,  which,  in 
the  developing  eye,  leads  to  gradual  distention  of  all  its 
coats.  The  appearance  thus  caused  is  illustrated  in  Fig. 
142.  The  globe  appears  large  and  prominent,  the  cornea 


FIG.  142.— Buphthalmos.    (From  a  patient  of  Dr.  Walter  B.  Johnson.) 

enlarged  (keratoglobus,  see  page  310),  and  the  sclera  bluish 
on  account  of  its  thinning.  The  lens  remains  small  and 
becomes  loosely  attached.  The  optic  disk  becomes  deeply 
cupped  and  sight  gradually  deteriorates.  The  refraction 
is  usually  myopic,  although  great  flattening  of  the  cornea, 
and  lack  of  development  of  the  lens  may  make  it  em- 
metropic  or  even  hyperopic.  A  few  cases  of  myopia, 


DISORDERS  OF  OCULAR  TENSION.  447 

starting  in  early  childhood,  and  continuing  slowly  pro- 
gressive, but  without  the  above  changes  in  the  anterior 
segment  of  the  eyeball,  are  probably  of  similar  character. 
Iridectomy  or  sclerotomy  offers  some  chance  of  checking 
the  disease. 


DIMINISHED  TENSION  OF  THE   EYEBALL. 

A  perforating  wound  of  the  eyeball  allowing  the  free 
escape  of  the  aqueous,  or  of  the  fluid  of  the  vitreous 
humor,  at  once  brings  the  intra-ocular  tension  down  to 
zero  where  it  remains  until  the  wound  has  become  suffi- 
ciently closed  to  prevent  further  outflow.  Then,  with  the 
process  of  healing,  the  intra-ocular  pressure  slowly  rises 
with  the  resisting  power  of  the  scar  until  it  reaches  nor- 
mal. Cwneal  fistula  will  continue  the  low  tension  in- 
definitely ;  and  cystoid  eicatrix,  due  to  inclusion  of  the 
iris  in  the  corneal  or  scleral  wound  and  its  imperfect 
closure,  with  drainage  of  intra-ocular  fluid  beneath  the 
conjunctiva,  may  also  keep  down  the  tension.  A  marked 
fall  of  tension  may  be  produced  in  the  normal  eye  by 
external  pressure,  as  from  a  tight  bandage. 

Some  cases  of  injury  to  the  eye  or  neighboring  parts 
present  prolonged  reduction  of  intra-ocular  tension ;  some- 
times lasting  for  weeks,  without  any  abnormal  opening 
for  the  escape  of  fluid.  This  may  be  due  to  a  nervous 
mechanism  for  regulating  intra-ocular  tension,  set  in 
action  by  injury  or  disease  within  the  eye.  Iridocyclitis 
is  apt  to  be  attended  with  lowered  tension  of  the  globe ; 
and  when  the  disease  terminates  unfavorably  the  soften- 
ing is  .permanent.  Cocain  causes  a  marked  decrease  of 
intra-ocular  tension,  possibly  by  mere  contraction  of 
intra-ocular  blood-vessels,  possibly  by  influence  on  a 
regulating  mechanism.  Lowered  tension  is  usually  an 
unfavorable  sign,  yet  there  may  be  restoration  to  normal ; 
and  even  the  prolonged  low  tension  does  not  render  im- 
possible the  restoration  of  useful  vision. 

Ophthalmomalacia  is  a  rare  condition,  characterized 
by  pain,  deep  injection,  photophobia,  and  diminished  ten- 


448  DISORDERS  OF  OCULAR  TENSION. 

sion  of  the  eye,  coming  on  without  known  cause,  and 
after  several  hours  or  days  ending  in  recovery.  Such  an 
attack  may  recur.  It  should  be  met  by  rest  and  protec- 
tion of  the  eyes,  the  use  of  a  weak  solution  of  physostig- 
min,  and  for  severe  pain,  hot  applications.  Tonics,  and 
attention  to  general  hygiene  are  indicated. 

BIBLIOGRAPHY. 

Glaucoma.      Its  Symptoms,  Varieties,   Pathology  and    Treatment. 

A.  W.  Stirling,  185  pages.  Jones  H.  Parker,  St.  Louis. 
Pathology  and  Treatment  of  Glaucoma.     Priestley  Smith,  210  Pages. 

J.  &  A.  Churchill,  London. 

Glaucoma.     J.  A.  Lippincott,  "  American  Text-book." 
Influence  of  Accommodation  on  Intra-ocular  Pressure.     C.  Hess  and 

L.  Heine,  "Ophthalmic  Review,"  Aug.,  1898. 
Glaucoma  and  the  Influence  of  Mydratics  and  Myotics.     Edward 

Jackson,  "Amer.  Jour,  of  Med.  Sci.,"  Apr.,  1898. 
Gout  and  Rheumatism  in  the  Etiology  of  Glaucoma.     S.  O.  Kichey, 

"Trans.  Congress  Amer.  Phys.  &  Surgeons,"  1897. 
Hemorrhagic  Glaucoma.     S.  D.  Risley,  "  Trans.  First  Pan-American 

Medical  Congress." 
Glaucoma  Treated  by  Resection  of  the  Sympathetic.     T.  Jonnesco, 

"  Ophthalmic  Review,"  July,  1898. 
Tension  in  Cases  of  Intra-ocular  Tumor.     C.  D.  Marshall,  "Trans. 

Oph.  Soc.  of  United  Kingdom,"  July,  1896. 
Buphthalmos.     Cross,  Hartridge,  and  Fischer,  "Trans.  Oph.  Soc.  of 

United  Kingdom,"  vol.  xvi. 
Hydrophthalmos.     Walter  L.  Pyle,  "Phila.  Monthly  Med.  Jour.," 

April,  1899;  "Annals  of  Ophthalmol.,"  July,  1899. 


CHAPTER    XVI. 

DISEASES   OF    THE    LIDS,   LACRIMAL    APPARATUS, 
ORBIT,  AND  ORBITAL  WALLS. 

INFLAMMATION  OF  THE  LIDS. 

BESIDES  the  inflammations  of  the  skin  and  of  the  con- 
junctiva there  are  disorders  of  considerable  clinical  im- 
portance that  may  be  considered  under  special  headings. 

Blepharitis  is  a.  term  applicable  and  sometimes  used 


DISEASES  OF  THE  LIDS.  449 

to  denote  any  inflammation  of  the  lids.  But  it  is  very 
often  used  as  synonymous  with 

Marginal  Blepharitis  (Blepharo-adenitis,  Blepharitis 
Ciliaris,  Ophthalmia  Tarsi,  Tinea  Tarsi,  etc.). — Redness 
of  the  lid-margins,  with  swelling,  involvement  of  the 
sebaceous  glands  with  excessive  secretion,  scaliness  of 
the  lid-margins,  sometimes  with  crusts  covering  excoria- 
tions or  distinct  ulcers,  and  disease  of  the  hair-follicles 
with  alteration  of  the  lashes,  is  a  common  clinical  picture. 
The  condition  is  essentially  chronic.  Sometimes  there  is 
only  recurring  redness  and  swelling  with  slight  scaliness, 
more  often  the  condition  is  constantly  present,  growing 
from  time  to  time  better,  and  again  worse.  It  may  last 
for  years,  causing  entire  loss  of  the  lashes,  and  permanent 
thickening  and  rounding  of  the  lid-border,  with  slight 
eversion  and  inflammation  of  the  exposed  conjunctiva 
(lippitudo.) 

The  disease  begins  in  childhood,  usually  in  the  scro- 
fulous and  poorly  cared  for.  It  is  closely  associated  with 
a  slight  chronic  conjunctival  irritation  or  inflammation, 
and  may  depend  on  nasal  disease.  Eye-strain  is  a  com- 
mon cause.  The  condition  gets  worse  from  use  of  the 
eyes,  or  exposure  to  wind  or  dust. 

Treatment. — Errors  of  refraction  should  be  carefully 
corrected.  Conjunctivitis,  or  lacrimal  or  nasal  disease 
must  have  appropriate  treatment ;  and  the  general  health 
and  hygienic  surroundings  must  be  looked  after.  Locally 
the  scabs  and  the  scales  should  be  softened  by  prolonged 
soaking  in  weak  soap-suds,  or  solution  of  sodium  bicar- 
bonate, and  thoroughly  removed.  All  lashes  that  are 
loose  or  which  show  inflamed  follicles  should  be  removed. 
Excoriations  and  ulcers  may  be  touched  with  silver  nitrate 
either  the  solid  stick  or  a  iO  per  cent,  solution.  A  weak 
ointment  of  yellow  oxid  of  mercury  should  be  well 
rubbed  into  the  lid-margin,  or  an  ointment  containing 
milk  of  sulphur,  or  resorcin,  may  be  used ;  or  the  scaly 
lid-margin  may  be  rubbed  daily  with  a  cotton  swab 
dipped  in  1  per  cent,  solution  of  formaldehyd.  The  latter 
will  cause  intense  irritation  if  it  comes  in  contact  with  the 

29 


450  MARGINAL  BLEPHARITIS. 

conjunctiva.  The  cleansing  and  anointing  of  the  lid- 
margins  should  be  repeated  at  bed-time,  and  the  treat- 
ment of  the  conjunctivitis  kept  up,  often  for  many  weeks. 

Stye  (hordeolum)  is  a  small  furuncle  situated  near  the 
lid-margin,  and  often  pointing  around  one  of  the  lashes. 
It  begins  with  a  small  red  and  painful  swelling  at  the 
edge  of  the  lid,  and  goes  on  to  suppuration  in  about  three 
to  six  days.  At  its  height  it  sometimes  causes  a  general 
swelling  of  the  lids  that  may  partly  conceal  the  original 
lesion  ;  but  which  quickly  disappears  when  the  stye  opens. 
Two  or  more  styes  may  occur  at  the  same  time,  and  there 
is  very  apt  to  be  a  succession  of  them.  They  are  caused 
by  a  predisposing  condition  of  general  health,  with  eye- 
strain,  and  local  infection  of  glands  or  hair-follicles  from 
conjunctivitis,  exposure  to  dust,  etc. 

Treatment. — The  individual  stye  may  sometimes  be 
aborted  by  local  applications  of  cold.  Generally  its 
course  is  hastened  and  rendered  more  favorable  by  bath- 
ing with  very  hot  water.  It  should  be  opened  when  sup- 
puration has  occurred  by  an  incision  made  with  a  cataract- 
knife  parallel  to  the  lid-margin.  To  prevent  farther 
recurrences,  eye-strain  should  be  removed  by  proper 
glasses  and  regulation  of  eye-work.  Conjunctivitis  or 
other  local  disease  should  be  properly  treated.  Internally 
a  laxative  should  be  given  with  tonics,  especially  iron. 
Potassium  bitartrate  taken  internally  seems  to  deserve  its 
popular  reputation  as  a  preventive  of  styes. 

Abscess  may  occur  in  any  part  of  the  lids.  It  is 
commonly  due  to  injury  or  orbital  disease.  It  should  be 
opened  early,  and  the  cavity  cleansed  with  hydrogen 
dioxid. 

Tarsitis,  inflammation  of  the  cartilage  of  the  lid,  is 
usually  due  to  syphilis  and  yields  to  antisyphilitic  treat- 
ment. It  is  marked  by  thickening  and  tenderness  of  the 
cartilage  over  which  the  skin  moves  freely.  It  may  also 
be  associated  with  marginal  Blepharatis,  or  with  trachoma, 
when  the  treatment  appropriate  for  those  affections  is 
indicated. 


DISEASES  OF  THE  LIDS.  451 

DISEASES  OF  THE  SKIN  OF  THE  LIDS. 

The  eyelids,  consisting  largely  of  skin,  are  subject  to 
most  of  its  diseases.  Some  of  these,  as  erythema,  and  the 
exanthematous  eruptions,  leprosy  and  some  rare  hyper- 
trophies, need  not  be  here  considered.  Others  require 
only  a  brief  mention  of  their  peculiarities  as  seen  in  this 
situation. 

Bcsema  is  caused  by  keeping  the  eye  bandaged,  by 
overflow  of  tears  in  conjunctival  or  corneal  disease  with 
excessive  lacrimation ;  or  it  may  occur  quite  apart  from 
ocular  disease.  It  may  be  treated  by  careful  cleansing 
with  warm  water  and  a  non-irritating  soap,  or  borax  solu- 
tion, and  then  dusting  with  a  mixture  of  equal  parts  of 
oxid  of  zinc,  lycopodium  and  starch  in  impalpable 
powder ;  or  if  the  surface  be  quite  dry,  zinc  ointment 
may  be  applied  daily,  taking  care  to  remove  the  old 
thoroughly  before  a  fresh  application.  In  chronic  cases 
other  recognized  treatment  for  eczema  may  be  required. 

Fissures  of  the  external  canthus  (rhagades)  arise 
under  the  conditions  which  cause  eczema ;  especially  if 
there  is  tight  closure  of  the  lids,  and  wrinkling  of  the 
skin  near  the  canthus  on  account  of  photophobia.  On 
stretching  the  folds  apart,  one  or  more  elongated  raw 
surfaces  appear.  The  condition  aggravates  a  tendency  to 
blepharospasm.  The  raw  surfaces  should  be  touched  with 
silver  nitrate,  either  in  stick  or  strong  solution.  In  an 
obstinate  case  it  may  be  worth  while  to  do  canthotomy. 

Toxic  dermatitis  (Rhus  Poisoning,  Dermatitis  Vene- 
nata,  and  Drug  Eruptions). — The  poison  oak,  and  poison 
ivy  are  capable  of  causing  a  violent  inflammation  of  the 
skin,  in  certain  susceptible  persons,  even  without  actual 
contact.  They  are  most  virulent  in  the  spring  and  early 
summer.  The  lesions  are  not  confined  to  the  lids,  but  the 
swelling  there  may  be  so  great  as  to  completely  close 
them.  There  is  intense  itching  and  burning,  and  the 
skin  may  be  dotted  with  small  papules  or  vesicles.  The 
treatment  includes  careful  protection  of  the  surface,  with 
soothing  lotions. 


452  DERMATITIS. 

A  few  patients  in  whom  the  mydriatics  cause  conjunc- 
tivitis may  also  suffer  from  violent  dermatitis,  with  heat, 
great  redness  and  swelling,  especially  of  the  lids.  The 
condition  quickly  improves  on  withdrawal  of  the  drug. 
In  toxic  dermatitis,  the  important  point  is  to  recognize  the 
cause,  usually  through  the  history  of  the  case. 

Erysipelas  usually  attacks  the  lids  by  extension  from 
other  parts  of  the  face.  It  causes  great  swelling,  the 
surface  being  red  and  tense.  It  is  distinguished  from 
other  diseases  of  the  lids,  by  the  general  symptoms  of  ill- 
ness. When  attended  by  deep  suppuration  it  may  cause 
orbital  abscess,  or  blindness  through  optic  neuritis,  or 
atrophy  from  pressure,  or  thrombosis  of  the  retinal 
vessels,  or  glaucoma.  The  treatment  is  that  of  erysipelas 
elsewhere ;  with  hot  fomentations,  and  early  free  incisions 
if  there  be  orbital  cellulitis. 

Herpes  poster  (zona,  shingles)  in  the  region  of  the 
ophthalmic  branch  of  the  fifth  nerve  is  of  special  import- 
ance because  of  the  strong  tendency  to  involve  the  cornea 
and  iris,  especially  when  vesicles  form  on  the  side  of  the 
nose.  It  is  sometimes  mistaken  for  erysipelas,  but  should 
be  easily  recognized  by  the  distribution  of  the  eruption 
limited  to  that  of  the  nerve,  and  always  limited  sharply 
at  the  median  line.  The  characteristic  neuralgic  and 
burning  pain  may  begin  before  the  eruption,  and  may 
last  for  months  afterward.  Motor  nerves  of  the  region 
may  also  suffer.  The  eruption  begins  with  groups  of 
bright  red  spots  on  which  vesicles  form  in  a  day  or  two, 
which  later  dry  up.  They  may  leave  permanent  scars, 
which,  years  later,  by  their  distribution,  furnish  sufficient 
basis  for  a  positive  diagnosis. 

The  vesicles  should  be  dusted  with  an  emollient  powder, 
and  carefully  protected  from  rupture.  Opium  or  acetan- 
ilid  may  be  given  internally  to  relieve  pain,  and  tonics, 
rest,  and  hygienic  measures  employed  to  build  up  the 
general  health. 

Molluscum  (mollmcum  contagiosum  or  epitheKale)  is  a 
rounded  dingy  white  or  red  tumor,  originating  in  a  seba- 
ceous gland,  sometimes  as  large  as  a  pea,  witli  a  dark 


DISEASES  OF  THE  LIDS.  453 

central  opening,  from  which  white  cheesy  contents  can  be 
squeezed  out.  These  tumors  may  occur  in  great  num- 
bers all  over  the  body.  The  disease  occurs  in  marked 
endemics  and  is  probably  contagious.  The  treatment 
consists  in  excising  each  individual  tumor. 

Warts  and  horn-like  growths  of  epithelium  occur 
in  the  lids  ;  the  latter  sometimes  attaining  the  length  of 
half  an  inch  or  more.  They  should  be  excised. 

Xanthelastna  (xanthoma,  vitiligoidea)  appears  on  the 
skin  of  the  lids  after  middle  life,  as  slightly  elevated,  flat, 
yellowish  patches,  compared  to  the  appearance  of  wash- 
leather,  symmetrically  placed  on  the  two  sides  of  the  face, 
and  slowly  increasing  in  area  until  they  may  cover  the 
greater  part  of  the  lids.  The  affected  skin  can  be  excised 
to  avoid  the  disfigurement,  but  the  patch  may  recur.  It 
is  harmful  in  no  other  way. 

Milium  is  a  minute,  white,  rounded  elevation  of  the 
surface  due  to  a  sebaceous  cyst.  Its  removal  (for  cos- 
metic reasons  only)  may  be  effected  by  digging  out  the 
cyst  with  a  needle,  or  puncturing  it  and  touching  it  with  a 
caustic  ;  or  by  electrolysis. 

Spontaneous  gangrene  of  the  skin  of  the  lids  is  a 
rare  disease.  It  may  recur,  and  may  prove  fatal. 

Syphilis. — The  primary  sore  may  occur  upon  the  lids, 
infection  being  carried  there  by  the  tongue  or  fingers. 
It  occurs  as  a  rounded  ulcer  with  an  extremely  hard  base, 
running  a  slow  course  with  very  little  pain  for  the  extent 
of  the  lesion,  with  swelling  and  induration  of  the  preauricu- 
lar  glands.  The  ulcer  should  be  kept  clean,  and  as  soon 
as  the  diagnosis  is  confirmed,  anti-syphilitic  treatment 
must  be  instituted. 

The  various  eruptions  of  secondary  and  hereditary 
syphilis  may  appear  on  the  lids.  Occasionally  an  ulcer 
due  to  the  breaking  down  of  a  gumma  is  met  with  after 
other  manifestations  of  the  disease  have  passed  away.  It 
is  liable  to  be  mistaken  for  lupus  or  rodent  ulcer.  When- 
ever such  an  origin  for  the  sore  is  possible,  anti-syphilitic 
treatment  should  be  thoroughly  tried.  The  influence  of 


454  SYPHILITIC  LESIONS. 

syphilis  in  causing  tarsitis  has  been  noted.     It  may  also 
cause  falling  of  the  eyebrows  or  lashes. 

DISEASE  OF  THE  LASHES  AND  EYEBROWS. 

The  hairs  here  as  elsewhere,  may  become  decolorized 
or  whitened  (canities,  poliosis),  or  fall  spontaneously  (alo- 
pecia). More  frequently  the  lashes  are  rendered  un- 
healthy, distorted  or  destroyed  by  inflammation  of  the  lid 
involving  their  roots. 

Pediculosis  (Phtkiriasis  Oilioruni). — The  pediculus 
pubis  or  crab  louse  is  sometimes  found  on  the  eyelashes. 
The  nits  or  ova  appear  as  numerous  pear-shaped  yellowish 
bodies  1  mm.  or  less  in  length,  each  glued  fast  to  a  hair. 
The  adult  louse  is  1  or  2  mm.  long,  flat,  oval,  gray  in 
color,  and  lying  close  to  the  skin  is  much  more  difficult  to 
see.  They  are  quickly  killed  by  careful  cleansing  of  the 
part,  and  rubbing  in  the  ointment  of  oxid  of  mercury  1 
to  60  or  stronger. 

Trichiasis ;  Distichiasis. — Displacement  of  the  eye- 
lashes becomes  of  practical  importance  when  it  is  such 
that  they  come  in  contact  with  the  cornea  or  conjunctiva, 
and  so  become  a  source  of  irritation.  Distichiasis  is 
strictly  the  condition  in  which  an  extra  row  of  lashes  on 
the  inner  lid-margin,  turn  toward  the  eye  while  all  the 
other  lashes  are  normally  directed.  Trichiasis  is  a  con- 
dition in  which  the  lashes  are  wrongly  directed  against 
the  eye,  but  there  is  no  inversion  of  the  lid-margin. 
Practically  the  two  have  the  same  significance,  and  in 
most  cases  trichiasis  is  essentially  a  commencing  entro- 
pion. 

Symptoms. — In  young  children  the  lashes  of  the 
lower  lid  are  sometimes  turned  in  against  the  eyeball. 
Apart  from  this  it  is  more  often  the  lashes  of  the  upper 
lid  that  are  misplaced.  The  rubbing  of  the  hair  against 
the  cornea  or  conjunctiva  causes  redness,  lacrimation, 
burning  and  the  feeling  of  a  foreign  body  in  the  eye ;  or 
it  may  cause  opacity  or  vascularity  of  the  cornea,  or  con- 
junctivitis with  purulent  discharge.  The  efforts  to  get 


DISEASES  OF  THE  LIDS.  455 

relief  by  forcible  closure  of  the  eyes,  may  make  matters 
worse  by  turning  in  additional  cilia.  After  removal  of 
the  offending  hairs  the  eye  is  better  until  they  grow  again, 
when  the  symptoms  are  renewed. 

Diagnosis. — Ingrowing  hairs  should  be  thought  of  in 
any  case  of  chronic  or  recurring  conjunctival  irritation, 
and  a  careful  search  made  for  them.  Often  they  are 
small,  and  of  a  light  color,  and  very  difficult  to  see. 
They  are  best  discovered  by  oblique  illumination,  and 
with  the  binocular  magnifier. 

Treatment. — If  few,  the  patient  may  prefer  to  simply 
have  the  displaced  lashes  pulled  out,  as  often  as  they  get 
long  enough  to  make  trouble,  or  they  may  be  permanently 
removed  by  electrolysis.  When  the  number  of  displaced 
lashes  is  large,  some  such  operation  as  is  recommended 
for  entropion  should  be  done. 

DISTORTIONS,  DISPLACEMENTS,  AND    ADHESIONS    OF 
THE  LIDS. 

Htttropion,  inversion  of  the  lid-margin,  may  be  pro- 
duced by  spasmodic  contraction  of  the  orbicularis  muscle, 
spasmodic  entropion.  This  is  favored  by  redundancy  of  the 
skin  in  childhood,  or  swelling  of  the  lids  after  injury,  or 
operation  about  the  eye ;  by  relaxation  of  the  skin  in  old 
age,  or  by  loss  of  support  of  the  lids  by  the  eyeball  as 
from  phthisis  bulbi,  atrophy  of  the  orbital  fat,  or  enuclea- 
tion.  It  may  be  brought  about  by  any  cause  of  ocular  irrita- 
tion ;  it  often  arises  while  an  eye  is  bandaged ;  and,  once 
started,  tends  to  increase  the  irritation  and  so  to  perpetuate 
itself. 

Entropion  is  also  associated  with  cicatricial  changes  in 
the  lids,  and  with  shrinking  of  the  conjunctiva  from 
chronic  disease,  especially  trachoma.  This  is  called 
organic  or  cicatricial  entropion.  It  is  usually  increased 
by  orbicular  spasm.  To  recognize  the  presence  and  ex- 
tent of  an  entropion  the  eyes  should  be  carefully  inspected 
without  touching  them.  Even  a  light  touch  on  the  lids 
may  be  sufficient  to  draw  the  lashes  away  from  the  eye- 
ball. 


456  ENTBOPION. 

Treatment. — Spasmodic  entropion  may  be  relieved  by 
removal  of  the  exciting  cause ;  or  by  keeping  the  lashes 
everted  for  a  time  by  a  strip  of  plaster,  or  by  painting 
the  carefully  dried  skin  with  collodion,  coat  after  coat ; 
or  by  keeping  a  fold  of  skin  pinched  up  with  forceps.  If 
the  above  measures  fail,  some  operation  must  be  per- 
formed. In  children  canthotorny  may  be  practiced.  In 
other  cases,  one  of  the  operations  described  in  Chapter 
XIX  may  be  resorted  to  for  the  upper  lid.  For  the 
lower  lid,  caustic  potash  may  be  applied  along  a  line 
parallel  with  the  lid-margin,  and  4  mm.  from  it  to  pro- 
duce eversion  by  the  eschar  it  causes. 

Uctropion. — Eversion  of  the  lid  so  that  the  conjunc- 
tival  surface  is  exposed,  may  result  from  swelling  of  the 
conjunctiva  (acute  ectropion).  The  effect  is  increased  by 
exophthalmos,  spasm  of  the  orbicularis  muscle,  and  ob- 
struction of  the  conjunctival  veins,  so  that  when  restored 
the  lid  promptly  turns  out  again,  weakness  or  paralysis 
of  the  orbicularis  muscle  allows  the  lower  lid  to  fall  away 
from  the  eyeball  and  the  conjunctiva  to  become  exposed 
(paralytic  ectropion). 

Organic  ectropion,  or  dragging  away  of  the  lid-margin 
from  its  normal  position  by  cicatricial  contraction,  occurs 
after  burns,  abscesses,  sloughing,  or  wounds  of  the  lids  and 
neighboring  parts.  The  exposed  conjunctiva  becomes  con- 
gested or  hypertrophied  ;  and  the  secretions,  with  the  tears, 
no  longer  passing  through  the  everted  punctum,  dry  upon 
the  exposed  conjunctiva  and  the  neighboring  skin,  and 
tend  to  aggravate  the  trouble. 

Treatment. — The  removal  of  the  cause  may  be  suffi- 
cient in  acute  ectropion,  or  incision,  or  excision  of  a  part 
of  the  everted  conjunctiva  may  be  needed.  Paralytic 
ectropion  often  requires  no  treatment,  or  the  lacrimal  pas- 
sages may  require  attention.  Or  it  may,  as  does  organic 
ectropion,  require  an  operation  which  must  be  specially 
planned  to  meet  the  needs  of  the  case  (see  Chapter  XIX). 

l/agophthalmos  (Palsy  of  the  Orbicular^).— Inability 
to  close  the  eyes  is  present  in  severe  organic  ectropion ; 
or  may  be  due  to  congenital  defect,  exophthalmos,  staphy- 


DISEASES  OF  THE  LIDS.  457 

loma,  or  paralysis  of  the  seventh  (facial)  nerve.  It 
may  be  associated  with  oculomotor  palsy  when  other 
parts  of  the  facial  nerve  escape.  The  puncta  not  being 
properly  applied  to  the  eyeball,  epiphora  results.  Strong 
effort  to  close  the  eye  causes  no  wrinkling  in  the  affected 
lids,  but  causes  the  eye  to  roll  upward.  The  turning  up 
of  the  cornea  usually  secures  it  sufficient  protection  in  lag- 
ophthalmos  to  prevent  its  destruction,  but  it  may  suffer 
from  exposure. 

Blepharospasm. — Annoying  twitching  of  the  lids, 
often  so  slight  as  to  be  unnoticed  except  by  the  patient,  is 
a  symptom  that  may  arise  from  the  instillation  of  physos- 
tigmin,  conjunctiva!  irritation,  eye-strain,  or  lack  of  nerve 
tone,  as  from  loss  of  sleep.  It  is  of  less  importance  than 
the  patient  often  thinks  it,  and  is  commonly  relieved  by 
removal  of  the  cause ;  but  in  some  patients  is  apt  to 
recur. 

Spasmodic  contraction  of  the  lids,  usually  with  those 
of  other  muscles  of  the  face  or  movements  of  the  head, 
are  seen  in  chorea.  Excessive  winking  is  seen  as  a  kind 
of  habit-chorea.  It  is  mostly,  at  least  in  the  beginning, 
associated  with  eye-strain,  or  local  irritation.  Spasmodic 
closure  of  the  lids  folknvs  the  entrance  of  an  irritant  into 
the  eye,  or  attends  corneal  disease,  or  fissure  of  the  skin 
near  the  outer  canthus.  In  rare  cases,  it  is  a  reflex  of 
irritation  in  the  nose  or  about  the  teeth.  Such  cases  are 
commonly  cured  by  removal  of  the  cause. 

The  most  serious  cases  are  those  of  tonic  spasm  without 
discoverable  local  cause.  The  closure  of  the  lids  may 
last  but  a  few  minutes,  or  for  hours,  or  even  weeks ;  and 
has  sometimes  been  succeeded  by  temporary  blindness. 
Section  of  the  nerve  may  afford  relief. 

Ptosis,  or  inability  to  raise  the  upper  lid,  may  be 
hysterical  or  due  to  paralysis  of  the  levator  muscle,  swell- 
ing or  hypertrophy  of  the  lid  or  neighboring  parts,  offer- 
ing a  mechanical  obstacle,  or  to  habitual  closure  of  one 
eye  to  avoid  blurred  vision,  or  to  congenital  defect. 

Paralytic  ptosis  is  usually  associated  with  other  evi- 
dences of  paralysis  of  the  oculomotor  nerve,  and  is  due 


458  PTOSIS. 

to  syphilis,  rheumatism,  pressure  of  the  nerve  by  hemor- 
rhage or  a  new  growth,  or  to  disease  of  the  central  nervous 
system.  The  completeness  of  the  paralysis  may  be  judged 
by  noting  if  on  looking  up  there  be  any  retraction  of  the 
skin  where  it  passes  from  the  lid  to  the  upper  margin  of 
the  orbit  where  normally  such  retraction  occurs.  The 
treatment  must  at  first  depend  on  the  cause.  But  if  after 
many  months  no  power  is  recovered  in  the  paralysed 
muscle,  the  trouble  may  be  somewhat  remedied  by  opera- 
tion (see  Chapter  XIX),  unless  the  uncovering  of  the  eye 
will  cause  diplopia  from  other  third  nerve  palsies. 

Congenital  ptosis  is  often  hereditary  and  associated 
with  other  congenital  defects.  In  a  few  cases  where  the 
lid  cannot  be  raised  alone,  it  can  be  raised  in  association 
with  movements  of  the  lower  jaw.  Congenital  ptosis 
may  be  due  to  hypertrophy  of  the  lids.  It  usually  allows 
the  patient  an  imperfect  use  of  his  eyes.  It  can  only  be 
remedied  by  operation,  or  mechanical  support  for  the  lid. 

EpicanthtiS  is  a  fold  of  skin  stretching  from  the  brow 
to  the  side  of  the  nose,  and  covering  more  or  less  com- 
pletely the  inner  canthus.  It  is  congenital ;  often  asso- 
ciated with  ptosis.  and  minor  degrees  of  it  are  frequently 
seen  in  early  childhood.  Usually  with  development  of 
the  nasal  bones  the  deformity  disappears.  It  may  be  les- 
sened by  removing  from  the  bridge  of  the  nose  a  piece  of 
skin  shaped  like  a  section  of  a  convex  lens,  and  then 
bringing  together  the  two  sides. 

BlepharophimosiS,  or  narrowing  of  the  palpebral 
fissure,  may  be  congenital,  or  due  to  adhesion  of  the  lids 
at  the  outer  canthus  after  ulceration,  or  to  cicatricial  con- 
traction of  the  lids  and  conjunctiva  from  trachoma.  It 
interferes  with  eversion  of  the  lids  for  local  applications ; 
and  greatly  increases  the  injurious  influence  of  rough  cica- 
tricial lids  upon  the  cornea.  On  these  accounts  it  is  often 
best  to  remedy  it  by  canthoplasty  (see  Chapter  XIX). 

Anchyloblepharon,  or  union  of  the  upper  and  lower 
lids  at  a  point  between  their  extremities,  may  be  congenital, 
in  which  case  it  may  be  relieved  by  simple  division.  But 
more  frequently  it  is  due  to  burns  or  similar  injuries,  and 


DISEASES  OF  THE  LIDS.  459 

is  associated  with  symblepharon  (see  page  269) ;  and  is  to 
be  treated  by  such  operations  as  the  symblepharon  may 
require. 

SWELLINGS  AND  TUMORS  OF  THE  EYELIDS. 

Edema. — The  loose  subcutaneous  tissue  and  redun- 
dant skin  of  the  lids  permit  of  the  rapid  accumulation  of 
serous  fluid  in  large  quantities,  and  its  equally  rapid  dis- 
appearance. A  small  stye  or  slight  injury  will  sometimes 
be  followed  by  enormous  swelling ;  and  severe  intra-ocular 
disease  or  injury  may  cause  similar  swelling.  Renal  dis- 
ease, heart  disease,  malaria,  arsenical  poisoning  etc.,  cause 
marked  edema  of  the  lids,  which  is  increased  while  lying 
down  and  diminished  when  in  the  erect  position.  In 
edema  from  such  causes  the  skin  is  pale  and  translucent. 
In  edema  from  local  inflammation  it  is  more  likely  to  be 
somewhat  red,  more  opaque,  and  often  tense  and  shining. 

Emphysema  of  the  lids  and  orbit  arises  as  part  of  a 
more  general  emphysema,  or  through  the  entrance  of  air 
from  the  air-cavities  of  the  head  into  the  subcutaneous 
cellular  tissue,  commonly  through  fractures  of  the  bones 
containing  these  cavities.  The  air  is  forced  into  the  tis- 
sues through  sneezing,  and  blowing  the  nose;  and  gives  rise 
to  a  soft  elastic  crackling  swelling  that  may  increase  with 
alarming  rapidity,  but  subsides  when  the  forcing  of  the 
air  into  the  tissues  is  stopped. 

Chalazion  (tarsal  cyst)  is  a  small  firm  rounded  tumor 
of  the  lid,  closely  attached  to  the  cartilage,  and  over 
which  the  skin  moves  freely.  It  develops  slowly,  often 
without  inflammation,  and  without  attracting  the  patient's 
attention  until  it  has  attained  some  size.  Two  or  more 
may  be  present  at  the  same  time.  It  is  most  frequent  in 
early  adult  life.  Often  mild  inflammatory  symptoms  are 
present  in  the  later  stages.  It  grows  for  several  months, 
becoming  the  size  of  a  pea  or  larger.  It  arises  from  a 
meibomian  gland,  and  consists  largely  of  granulation- 
tissue  surrounded  by  a  membranous  wall.  It  is  not  a 
retention-cyst,  but  its  contents  may  undergo  softening  so 


460  CHALAZION. 

that  it  becomes  an  encysted  abscess.  It  is  annoying  on 
account  of  its  appearance,  and  the  sense  of  weight  or 
stiffness  it  causes  in  the  lid. 

The  conjunctiva  opposite  the  growth  shows  a  spot  of 
lighter  yellow,  or  gray  color ;  and,  if  undisturbed,  after 
many  months  the  chalazion  may  open  through  this  spot, 
discharge  its  fluid  contents  into  the  conjunctival  sac,  and 
slowly  contract.  After  it  opens,  the  granulation-tissue  is 
apt  to  fill  the  cavity  and  may  protrude  on  the  conjunctival 
surface.  A  small  chalazion  may  disappear  spontaneously 
without  opening,  or  at  an  early  stage  its  contents  may  be 
pressed  out. 

Treatment. — This  is  operation  by  incision  or  excision, 
(see  Chapter  XIX),  and,  if  either  be  present,  the  removal 
of  eye-strain  or  chronic  conjunctivitis  to  prevent  a  recur- 
rence. 

I/ipoma. — Accumulation  of  fatty  tissue  in  the  lids  is 
rare.  It  may  occupy  the  whole  or  a  limited  portion.  If 
it  be  unsightly  or  interfere  with  the  lid-movements,  it 
may  be  excised.  Fibroma,  a  firm  tumor,  often  present  at 
birth  and  enlarging  years  later,  occurs  in  the  lids.  Neu- 
roma and  cysticerctis  of  the  lid  have  been  reported. 
Dermoid,  lymphoid,  and  other  tumors  of  the  orbit  fre- 
quently involve  the  lids. 

Angioma  (nevus,  vascular  tumor)  of  the  lid  may  vary 
from  the  superficial  capillarity  which  makes  a  "  mother's 
mark"  to  a  collection  of  large  vascular  sinuses  having  a 
definite  wall  (cavernous  angiomd),  or  masses  of  large 
dilated  vessels  (telangiectasis),  which  may  extend  deeply  in 
the  orbit,  or  be  associated  with  abnormalities,  or  the 
retinal  or  choroidal  vessels.  Such  growths  appear  at  or 
shortly  after  birth,  and  often  tend  to  increase  in  size,  at 
least  for  a  time.  A  few  spontaneously  disappear. 

Diagnosis. — A  vascular  tumor  can  be  recognized  by 
its  variability  in  size.  When  the  child  cries,  or  is  held 
head  down,  the  tumor  noticeably  enlarges.  By  firm 
pressure  it  may  be  reduced,  or  caused  to  disappear.  If 
not  thus  reducible,  it  is  commonly  connected  with  an  artery 
of  some  size,  and  exhibits  decided  pulsation. 


DISEASES  OF  THE  LIDS.  461 

Treatment. — For  a  superficial  nevus  cauterizing  with 
nitric  acid,  or  sodium  ethylate,  may  be  resorted  to.  The 
caustic  is  applied  with  a  glass  rod.  The  eschar  must  be 
left  undisturbed  until  it  separates  spontaneously,  the 
caustic  being  applied  repeatedly  if  needed.  Vaccination 
of  the  nevus  has  affected  its  removal.  A  larger  or  deeper 
angioma,  if  diminishing,  should  be  let  alone ;  and  if 
stationary,  should  be  attacked  with  great  caution.  But 
if  clearly  increasing,  it  should  be  promptly  excised,  or 
ligated  by  multiple  ligatures,  or  subjected  to  electrolysis. 
Excision  is  on  the  whole  most  satisfactory ;  but  the  sur- 
geon should  always  start  prepared  for  a  serious  operation. 
Electrolysis  may  be  afterward  resorted  to  for  small  por- 
tions that  escape  excision. 

Sarcoma. — Primary  sarcoma  may  occur  in  the  lids. 
If  not  pigmented,  it  somewhat  resembles  chalazion,  for 
which  it  has  been  mistaken.  It  should  be  promptly  and 
completely  excised ;  and  even  then  may  recur. 

l/upus  (tuberculosis  of  the  skin)  occurring  on  the  face 
may  involve  the  eyelids,  and  may  extend  thence  to  the 
conjunctiva.  It  must  be  borne  in  mind  in  connection  with 
the  diagnosis  of  syphilis  and  epithelioma. 

Kpithelioma  (rodent  ulcer,  Jacob's  nice)")  begins  most 
frequently  on  the  margin  of  the  lower  lid,  as  a  flat  thick- 
ening of  the  skin  most  prominent  and  hard  at  the  mar- 
gins. It  begins  usually  after  middle  life,  and  may  remain 
with  no  change  except  a  slight  extension  of  its  surface  for 
many  years.  Then  the  center  ulcerates,  and  becomes 
covered  with  a  brownish  crust.  After  this  the  ulceration 
keeps  pace  with  the  deposit,  slowly  extending  until  it 
may  destroy  a  large  portion  of  the  face  without  involving 
the  lymphatic  glands,  or  giving  rise  to  secondary  de- 
posits. 

Diagnosis. — In  a  typical  case  the  appearance  is  char- 
acteristic, but  local  irritants  or  attempts  at  treatment  may 
disguise  it ;  and  syphilitic  ulceration  might  be  mistaken 
for  it.  The  syphilitic  ulcer  develops  more  rapidly,  and 
has  softer,  punched-out  edges.  Where  there  is  the  slight- 
est doubt,  energetic  antisyphilitic  treatment  should  be 


462  EP1THELIOMA. 

tried.  Lupus  starts  in  early  life,  usually  on  some  other 
part  of  the  face,  extends  by  the  formation  of  isolated 
nodules  which  later  coalesce,  has  softer  and  less  definite 
edges,  is  attended  with  more  redness  and  inflammation  of 
neighboring  parts,  lacks  the  characteristic  ulcer  of  epi- 
thelioma,  and  runs  even  a  slower  course.  Epithelioma 
of  the  lids  sometimes  assumes  the  form  seen  elsewhere, 
forming  a  thick  mass  that  breaks  down  at  the  center  and 
extends  with  comparative  rapidity. 

Treatment. — The  growth  should  be  completely  ex- 
cised at  the  earliest  possible  moment,  and  the  loss  of  tissue 
replaced,  if  needful,  by  a  plastic  operation.  Where  ex- 
cision is  not  practicable,  erasion  (the  very  thorough  curet- 
ting of  the  whole  surface),  or  the  actual  cautery,  or 
parboiling  by  frequent  fomentations  as  hot  as  can  be 
possibly  borne,  or  application,  of  chloracetic  acid,  nitric 
acid,  formaldehyd  solution,  or  a  saturated  solution  of 
potassium  chlorate  in  glycerin  and  water,  may  be  tried. 

Burns  of  the  lids,  if  small,  heal  quickly  and  cause  no 
trouble,  but  if  extensive  they  cause  permanent  deform- 
ity of  the  lids,  through  cicatricial  contraction.  They 
should  be  treated  by  exclusion  of  air,  either  by  a  dressing 
of  carbolized  oil  and  lime-water,  or  by  lint  soaked  in  a 
solution  of  borax  or  sodium  bicarbonate.  After  two  or 
three  days  the  surfaces  should  be  cleansed  once  daily  and 
dusted  with  iodoform.  Extensive  granulating  surfaces 
should  be  covered  with  skin-grafts. 

Other  injuries  of  the  lids  are  considered  in  Chapter 
XVII. 


DISEASES  OF  THE   LACRIMAL  PASSAGES. 

Upiphora  (Stillicidium  Lacrimarum,  Watery  Eye). — 
The  tears  secreted  to  keep  moist  the  surface  of  the  cor- 
nea, and  remove  irritants  from  the  conjunctival  sac,  pass 
normally  through  lacrimal  passages  into  the  nose. 
Failure  of  the  lacrimal  drainage-system  to  remove  the 
tears  fast  enough  causes  them  to  accumulate  in  the  eye, 
and  run  over  the  edge  of  the  lid. 


DISEASES  OF  THE  LACRIMAL  APPARATUS.      463 

The  amount  of  lacrimal  secretion  varies  greatly  in 
health,  in  response  to  nerve-impulses  sent  to  the  gland.  It 
can  be  enormously  increased,  as  by  emotion,  exposure  of 
the  eye  to  wind,  dust,  or  irritating  vapors,  or  disease,  par- 
ticularly inflammation  of  the  cornea  or  iris.  The  drainage- 
system,  parts  of  which  are  little  more  than  tubes  of 
capillary  size,  failing  to  dispose  of  the  increased  secretion, 
overflow  results — excessive  lacrimation  (reflex  epiphora}. 
Epiphora  of  this  kind  may  result  from  irritation  of  the 
lacrimal  passages  themselves,  or  even  of  the  nose.  It 
may  also  arise  from  retinal  impressions,  as  a  bright  flash 
of  light,  or  from  the  effect  of  moderate  light  upon  an 
over-sensitive  retina. 

Every  case  of  epiphora  should  be  carefully  considered, 
with  reference  to  its  possible  origin  in  one  of  these  sources 
of  reflex  action.  Even  where  there  is  obvious  organic 
disease  of  the  lacrimal  passages,  this  in  itself  raises  a 
presumption  of  accompanying  reflex  epiphora,  and  the 
share  this  has  in  the  symptoms  should  be  carefully  con- 
sidered. 

Treatment. — To  remove  an  excessive  reflex  as  to  light 
or  the  rush  of  air  in  riding  a  bicycle,  the  eye  must  be 
accustomed  to  the  stimulus,  and  any  excessive  irritability 
of  the  nervous  system  reduced  as  far  as  possible.  The 
treatment  of  epiphora  due  to  obstruction  of  the  lacrimal 
passages  will  be  considered  in  connection  with  the  various 
diseases  which  cause  it. 

Closure  (Atresia)  of  the  Ptmctum. — Closure  of 
the  punctum  may  be  congenital,  or  may  arise  from  the 
eversion,  and  non-use  of  the  punctum,  or  from  disease  or 
injury  to  the  parts.  It  may  affect  one  or  more  of  the 
puncta.  If  the  canaliculis  is  normal,  the  punctum  may 
be  openeoT,  and  dilated  with  a  fine-pointed  probe.  An 
ordinary  pin  with  a  good  point  is  well  adapted  to  the 
purpose.  The  proper  position  for  the  punctum  having 
been  determined,  this  point  should,  with  a  slight  rotary 
motion,  be  thrust  into  it,  until  it  is  well  dilated.  The 
dilatation  may  need  to  be  repeated  a  few  times  to  make 
it  permanent.  Closure  of  the  punctum  with  closure  of 


464  CLOSURE  OF  THE  PUNCTUM. 

the  canaliculus  must  be  treated  as  for  the  latter  con- 
dition. 

Displacement  of  the  Punctum. — The  normal 
punctum  is  directed  toward  the  eyeball  where  it  reaches 
and  draws  in  by  its  capillary  action  the  thinnest  film  of 
tears.  When  the  punctum  is  located  on  the  edge  of  the 
lid  instead  of  on  the  inner  margin,  or  when  the  lid  is 
somewhat  everted,  the  tears  before  reaching  it  must 
accumulate  to  an  abnormal  extent,  and  perhaps  flow  over 
the  lid-margin.  This  is  a  common  cause  of  epiphora. 
Misplacement  of  the  punctum  in  the  lid  may  be  congeni- 
tal. Eversion  may  be  due  to  any  cause  of  ectropion  or 
lagophthalrnos,  to  slight  thickening  and  rounding  of  the 
lid-margin  in  blepharitis,  or  to  swelling  in  conjunctivitis, 
contraction  of  the  skin  of  the  lid  near  the  punctum,  or 
senile  relaxation  of  the  lower  lid.  It  may  be  quite 
sufficient  to  cause  serious  epiphora,  although  there  is 
no  displacement  of  the  lid  noticed  on  casual  inspec- 
tion. 

Treatment. — If  the  cause  of  the  eversion  of  the  punc- 
tum can  be  removed,  as  by  cure  of  conjunctivitis,  bleph- 
aritis, or  facial  paralysis,  or  restoration  of  the  lid-border 
to  normal  position  in  ectropion,  this  may  cure  the  e ver- 
sion. If  this  cannot  be  done,  it  is  customary  to  slit  the 
canaliculis.  (See  Chapter  XIX.) 

Obstruction  of  the  canaliculus  may  occur  through 
stricture,  inflammatory  swelling  of  its  lining  membrane, 
pressure  from  without,  by  polypi,  or  from  a  foreign  body, 
as  an  eyelash,  or  a  "tear  stone"  (dacryolith)  within  it. 
The  latter  is  a  mass,  consisting  largely  of  calcium  phos- 
phate, formed  by  the  presence  of  a  Icptothrix,  a  filament- 
ous form  of  bacteria.  Or  the  canaliculus  may  be  absent  as 
a  congenital  anomaly,  or  destroyed  by  traumatism. 

Treatment. — Inflammatory  swelling  may  be  reduced 
by  appropriate  treatment  to  the  adjoining  conjunctiva 
and  the  lining  membrane  of  the  lacrimal  sac,  which  are 
always  involved.  Stricture  may  be  dilated  by  passing 
successively  larger  probes  from  1  to  4  or  6  (see  Chapter 
XIX) ;  although  a  permanent  cure  usually  requires 


DISEASES  OF  THE  LACRIMAL  APPARATUS.     465 

slitting  of  the  canaliculis,  which  is  also  necessary  when 
foreign  bodies  must  be  extracted. 

Obstruction  of  the  Nasal  Duct. — This  is  com- 
monly due  to  partial  or  complete  closure,  through  nasal 
disease,  of  the  duct  where  it  enters  the  nose,  to  inflam- 
matory swelling  of  its  lining  membrane,  to  fibrous  strict- 
ure usually  situated  at  the  upper  end,  or  to  disease  of  the 
bony  walls  surrounding  it.  It  always  causes  epiphora, 
with  swelling  of  the  lacrimal  sac  and  regurgitation  of 
its  contents  into  the  conjunctival  sac  under  pressure. 

If  the  obstruction  continues  any  length  of  time,  it  is 
attended  with  inflammation  of  the  lining  membrane  of 
the  sac,  which  is  usually  catarrhal  but  often  becomes 
purulent.  The  regurgitation  of  the  contents  of  the  sac 
extends  the  inflammation  to  the  conjunctiva,  setting  up 
and  keeping  up  a  chronic  conjunctivitis,  often  called 
lacrimal  conjunctivitis. 

Diagnosis. — The  swelling  of  the  sac  is  seen  as  an 
ovoid  swelling  (lacrimal  tumor,  mucocele),  situated  at  the 
side  of  the  nose  and  extending  more  below  the  canthus 
than  above.  This  tumor  varies  in  size  from  time  to  time, 
and  may  entirely  disappear  under  firm  pressure  which 
forces  out  the  contents  of  the  sac.  The  situation  of  the 
swelling,  and  its  diminution  with  the  regurgitation  of 
its  contents  into  the  conjunctiva,  are  very  characteristic. 
In  some  cases  a  portion  of  the  contents  may,  under  pres- 
sure, be  forced  into  the  nose.  An  important  point  is  to 
try  whether,  by  means  of  the  lacrimal  syringe,  fluid  can 
still  be  forced  through  the  obstructed  duct  into  the  nose. 

Treatment  is  directed  toward  re-establishing  a  suffi- 
cient passage  from  the  lacrimal  sac  into  the  nose.  In 
some  cases  treatment  of  the  nose,  as  the  removal  of  con- 
stricting bands  or  scars,  or  hypertrophy  of  the  lower  tur- 
binals  behind  which  the  duct  opens,  will  be  sufficient. 
In  other  cases,  cure  of  an  inflammation  of  the  mucous 
membrane  of  the  sac  and  duct  may  reopen  the  latter  by 
reduction  of  the  swelling.  For  this  purpose  the  passages 
should  be  regularly  syringed  out  with  a  solution  of  pro- 
targol  or  pyoktanin,  and  the  patient  instructed  to  fre- 

30 


466  OBSTRUCTION  OF  THE  NASAL  DUCT. 

quently  empty  the  sac  by  pressure  upon  it.  Any  ab- 
normality of  the  puncta  or  canaliculi  which  would  inter- 
fere with  the  flow  of  fluid  through  the  duct  must  be  cor- 
rected, for  the  health  of  the  lacrimal  passages  cannot  be 
secured  without  the  free  flow  of  tears  through  them.  The 
above  measures  will  often  give  permanent  relief,  if  the 
obstruction  is  still  incomplete  or  intermittent. 

For  the  more  serious  cases  it  is  necessary  to  slit  a  cana- 
liculis,  preferably  the  upper,  unless  the  lower  is  displaced 
or  obstructed,  and  to  probe  the  duct  (see  Chapter  XIX). 
The  passage  having  thus  been  opened  the  lumen  must  be 
maintained,  either  by  the  repeated  passing  of  the  probe, 
or  by  the  continuous  wearing  of  a  style  until  the  tendency 
to  re-contraction  of  the  stricture  has  been  fully  overcome. 
The  probes  used  should  be  as  large  as  can  readily  be  pa>sed, 
3  mm.  in  diameter  or  even  larger.  But  the  re-establish- 
ment of  the  lacrimal  passages  by  probing  is  a  very  serious 
undertaking,  to  be  reserved  for  skilled  hands  and  for 
exceptional  cases.  Often  the  process  can  be  hastened  by 
cutting  the  stricture  (Chapter  XIX),  followed  by  the  in- 
sertion of  a  style  of  about  3  mm.  diameter. 

Sometimes  absorption  is  hastened  by  connecting  the 
probe,  while  in  situ,  with  the  negative  pole  of  a  galvanic 
battery,  and  passing  through  it  a  current  of  about  2  mil- 
liamperes  for  2  to  5  minutes.  Disease  of  the  bony  walls 
of  the  lacrimal  canal  usually  requires  prolonged  treat- 
ment or  a  radical  operation  for  the  removal  of  diseased 
bone.  Where  it  becomes  impossible  to  establish  a  per- 
manent passage  for  the  tears  into  the  nostril,  the  patient's 
condition  will  be  most  improved  by  complete  obliteration 
of  the  lacrimal -sac.  (Chapter  XIX.) 

Prognosis. — Lacrimal  obstruction  so  serious  as  to 
require  operative  treatment  is  not  followed  by  restoration 
of  the  passages  to  normal.  The  slit  canaliculis  never 
takes  the  tears  from  the  eye  quite  as  nicely  as  the  normal 
passage  ;  and  permanent  maintainance  of  a  capillary  pas- 
sage cannot  be  hoped  for.  Relative  cure  is  obtained  by 
establishing  an  abnormally  large  and  patulous  canal,  more 
likely  than  the  normal  canal  to  receive  irritants  both  from 


DISEASES  OF  THE  LACRIMAL  APPARATUS.      467 

the  conjunctiva  and  from  the  nose.  Through  such  a  canal, 
air  and  nasal  discharges,  may  be  blown  into  the  eye,  in 
blowing  the  nose.  Relief  may  be  obtained  from  the  more 
serious  effects  of  lacrimal  obstruction  ;  but  only  by  pain- 
ful and  tedious  measures. 

I/acrimal  Abscess. — Allusion  has  been  made  to 
the  chronic  inflammation  of  the  lacrimal  passages  that 
attends  obstruction.  If  this  continues  there  is  great 
liability  to  more  acute  inflammation  of  the  sac,  acute 
dacryocystitw,  with  infection  of  the  surrounding  cellu- 
lar tissue,  and  the  formation  of  an  abscess.  The  tumor 
caused  by  distension  of  the  sac  becomes  enlarged,  red,  and 
painful,  tending  to  extend  rather  downward;  and  if  let 
alone  softens  and  breaks,  establishing  a  false  vent  for  the 
contents  of  the  sac,  a  lacrimal  fistula. 

Treatment. — The  canaliculus  should  be  slit  so  as  to 
make  quite  a  free  opening  into  the  sac,  and  if  near  the 
point  of  breaking,  the  abscess  may  also  be  opened  exter- 
nally. Both  sac  and  abscess  cavity  are  then  to  be 
thoroughly  cleansed  with  hydrogen  dioxid  solution  ;  and 
after  a  day  or  two  when  the  extreme  soreness  of  the  parts 
has  somewhat  abated,  the  passage  should  be  re-established 
into  the  nose.  Only  the  removal  of  the  obstruction  or 
the  complete  destruction  of  the  sac  will  secure  the  closure 
of  a  lacrimal  fistula  or  the  permanent  healing  of  the 
parts. 

DISEASES  OF  THE  LACRIMAL  GLAND. 

Inflammation  (daeryo-adenitis)  is  rare,  and  commonly 
secondary.  It  has  been  associated  with  mumps,  syphilis, 
gonorrhea,  rheumatism,  and  septic  absorption,  usually 
it  is  chronic,  giving  rise  to  redness  and  swelling  of  the 
upper  lid,  and  a  firm  tumor  which  may  be  felt  on  palpa- 
tion at  the  upper  and  outer  margin  of  the  orbit,  with 
injection  of  the  adjoining  conjunctiva.  Acute  inflamma- 
tion may  go  on  rapidly  to  suppuration,  with  enormous 
swelling  of  the  lids. 

Chronic  inflammation  should  be  treated,  by  attention  to 
any  general  disease,  with  mercury  and  iodids  internally, 


4U8  DACRYO-ADESITIS. 

and  cautious  massage  of  the  part  with  mercuric  oxid 
ointment.  Acute  inflammation  requires  hot  applications 
and  early  incision.  If  a  fistulous  opening  be  found  in  the 
skin  of  the  lid,  it  may  be  transferred  to  the  conjunctival 
surface,  by  a  ligature  passed  into  and  around  it,  tied  on 
the  coujunctival  surface  and  tightened  until  it  cuts 
through. 

Hypertrophy,  or  enlargement  of  the  gland,  may  be 
congenital  or  may  follow  syphilis.  It  is  sometimes  so 
great  as  to  displace  the  eyeball  and  cause  great  deformity. 
Extirpation  of  the  gland  should  be  done  before  the 
enlargement  becomes  so  excessive ;  but  prolonged  anti- 
syphilitic  treatment  should  first  be  tried. 

Prolapse  or  dislocation  of  the  gland  so  that  it  can 
be  felt,  or  its  position  seen  below  the  margin  of  the  orbit 
is  not  very  rare.  The  gland  has  sometimes  been  extirpated 
for  extreme  prolapse. 

Cyst  of  the  lacrimal  gland  (dacryops)  is  due  to  obstruc- 
tion of  one  or  more  of  its  ducts.  It  appears  as  a  bluish 
translucent  tumor,  beneath  the  conjunctiva  of  the  upper 
lid,  sometimes  varies  in  size,  the  obstruction  being  incom- 
plete, and  is  notably  increased  by  anything  that  provokes 
the  secretion  of  tears.  It  may  be  incised,  and  the  incision 
repeatedly  opened  until  its  edges  have  healed.  Or  a 
suture  may  be  passed  through  its  walls  and  allowed  to  cut 
itself  out. 

Tumors  of  the  lacrimal  gland  are  rare.  Chalky  con- 
cretions sometimes  form  in  it ;  and  adenoma,  sarcoma, 
myxoma,  epithelioma,  osteochondroma,  lymphoma,  and 
hydatid  cyst  of  the  gland  have  been  met  with. 

DISEASE  OF  THE  ORBIT   AND  ORBITAL  WALLS. 

Orbital  Cellulitis  (Abscess  or  Phlegmon  of  the  Orbit}. 
— Symptoms. — Inflammation  of  the  cellular  tissue  of 
the  orbit  begins  with  deep  orbital  pain,  headache,  limita- 
tion of  ocular  movements,  protrusion  of  the  eye,  swelling 
and  dusky  redness  of  the  lids  and  conjunctiva.  Retinal 
hemorrhage,  and  neuroretinitis  to  be  followed  by  optic 


DISEASES  OF  THE  ORBIT.  469 

atrophy,  may  attend  inflammation  behind  the  globe  ;  and 
sloughing  of  the  cornea  may  occur  when  there  is  great 
swelling  at  the  front  of  the  orbit.  Panophthalnritis  may 
occur.  In  the  more  violent  cases,  a  general  chill  occurs 
at  the  outset,  followed  by  fever,  and  marked  evidence  of 
general  illness. 

Course  and  Varieties. — It  may  develop  in  facial 
erysipelas,  in  which  case  both  orbits  are  mostly  involved, 
may  follow  excessive  exposure  to  cold  or  acute  fevers, 
especially  typhoid  and  scarlatina,  may  arise  by  metastasis 
in  pyemia,  or  from  local  injury,  panophthalmitis,  periosti- 
tis of  the  orbit  or  similar  disease  of  the  neighboring 
parts. 

Diagnosis. — Orbital  cellulitis  must  be  distinguished 
from  panophthalmitis  by  the  absence  of  opacity  of  the 
dioptric  media,  or  other  evidence  of  suppuration  within 
the  globe ;  from  purulent  conjunctivitis  in  which  there  is 
more  conjunctival  discharge  and  no  exophthalmos  or 
limitation  of  ocular  movements ;  and  from  thrombosis  of 
the  cavernous  sinus,  which  is  marked  by  great  swelling  in 
the  orbit,  with  pain  and  obstruction  of  the  circulation, 
but  which  may  be  distinguished  by  the  presence  of  cere- 
bral symptoms,  palsies  of  certian  ocular  muscles,  before 
general  immobility  of  the  eyeball  occurs,  and  by  the 
pre-eminence  of  the  venous  element  in  the  hyperemia. 
But  the  diagnosis  might  be  complicated  by  the  superven- 
tion of  the  orbital  inflammation  on  either  of  the  other 
conditions  mentioned. 

Treatment. — The  cellulitis  should  be  carefully  at- 
tended to,  especially  if  it  is  a  local  suppuration,  or  perios- 
titis. The  patient  should  be  put  to  bed,  and  full  doses 
of  tincture  of  chlorid  of  iron,  with  moderate  doses  of 
quinin  and  such  other  general  treatment  as  may  be  indi- 
cated. Blood  should  be  taken  from  the  temple  freely  in 
the  early  stage.  Hot  fomentations  should  be  applied  at 
short  intervals.  As  soon  as  there  is  evidence  of  any  pus- 
collection,  it  should  be  given  free  vent.  But  earlier  than 
this,  if  the  swelling  is  very  great,  deep  incisions  should 
be  made  near  the  orbital  margins.  If  practicable,  these 


470  ORBITAL  CELLULITIS. 

should  be  made  from  the  conjunctiva,  being  preceded,  if 
necessary,  by  canthotomy.  But  if  necessary  they  should 
be  made  through  the  lids,  avoiding  the  position  of  the 
oblique  muscles.  In  facial  erysipelas,  additional  incisions 
may  be  required  in  the  lids.  If  panophthalraitis  super- 
venes, an  incision  should  be  made  through  the  cornea 
that  will  let  out  all  the  contents  of  the  globe ;  or  the  eye- 
ball may  be  enucleated. 

The  incisions  should  be  washed  out  with  hot  antiseptic 
solutions,  and  the  fomentations  continued  until  the  swell- 
ing begins  to  subside. 

Prognosis. — Orbital  cellulitis  endangers  the  sight 
through  ocular  inflammation  and  optic  atrophy ;  and  it 
endangers  life  through  thrombosis  or  extension  into  the 
cranium,  especially  when  due  to  erysipelas. 

Inflammation  of  the  oculo-orbital  fascia  (ten- 
onitis)  may  be  caused  by  gout,  rheumatism,  influenza,  in- 
flammations of  the  eyeball,  or  injury,  especially  operation 
on  the  ocular  muscles.  It  is  indicated  by  swelling  of  the 
lids,  particularly  the  upper,  pain  on  the  movement  of  the 
eye;  and  conjunctival  edema  which  may  be  limited  to  a 
small  portion  of  the  membrane.  If  not  caused  by  injury 
of  the  orbital  tissue  it  is  not  attended  by  suppuration, 
but  it  gives  rise  to  extensive  fibrous  adhesions  of  the 
globe,  which  hinder  enucleation  of  the  eye  if  this  becomes 
necessary. 

It  should  be  treated  by  rest  of  the  eyes,  and  dry  heat 
or  occasional  hot  fomentations.  Internally  iodids,  salyci- 
lates,  potassium  acetate,  or  colchicum  may  be  given,  with 
saline  laxitives,  and  anodynes,  if  necessary.  For  sup- 
purative  cases,  free  drainage  for  pus,  and  frequent  hot 
irrigations  or  fomentations,  are  to  be  employed. 

Periostitis,  Caries  and  Necrosis. — Acute  general 
periostitis  of  the  orbit  causes  the  symptoms  of  orbital 
cellulitis  due  to  it.  Chronic  periostitis  gives  rise  to 
thickening  of  the  periosteum,  which,  if  not  deeply  situ- 
ated, may  be  felt  as  a  hard  immovable  swelling, — fibrous 
thickening,  or  a  soft  fluctuating  mass — abscess.  There  is 
deep-seated  pain  in  the  orbit,  and  may  be  tenderness  to 


DISEASES  OF  THE  ORBIT.  471 

pressure.  There  may  or  may  not  be  exophthalmos  or 
other  displacement  of  the  eyeball.  The  disease  is  usually 
due  to  syphilis,  tuberculosis,  disease  of  the  neighboring 
cavities,  or  traumatism,  the  latter  often  acting  as  an  ex- 
citing cause.  If  suppuration  occurs,  the  abscess  slowly 
makes  its  way  to  the  surface,  the  skin  becomes  reddened, 
and  upon  the  opening  of  the  abscess  a  sinus  is  discovered 
with  bare  carious  bone  at  the  bottom.  In  rare  cases  a  con- 
siderable fragment  of  bone  may  be  present.  The  fistula 
thus  established  tends  to  become  chronic.  If  the  open- 
ing is  near  the  orbital  margin,  the  skin  becomes  firmly 
adherent  to  the  bone,  causing  deformity  of  the  lids.  If 
the  sinus  opens  into  the  conjunctiva,  its  origin  is  probably 
quite  deep  in  the  orbit. 

Diagnosis. — Chronic  periostitis  starting  deep  in  the 
orbit  may  cause  no  distinctive  symptoms  until  it  extends 
well  forward.  Near  the  orbital  margin  the  swelling  it 
causes  might  be  confused  with  gumma  of  the  orbit,  a 
mistake  usually  not  serious,  since  syphilis  is  the  most  fre- 
quent cause  of  periostitis.  Where  a  sinus  exists,  care 
should  be  taken  to  make  sure  that  it  is  not  caused  by  a 
foreign  body,  lodged  in  the  orbit  unknown  to  the  patient, 
at  the  time  of  an  injury  to  which  the  periostitis  is  ascribed. 
Careful  search  must  also  be  made  for  a  cause  of  the  disease 
in  the  neighboring  sinuses  connected  with  the  nose. 

Treatment. — Periostitis  without  suppuration  should  be 
treated  with  mercury  and  large  doses  of  potassium  iodid, 
or  cod-liver  oil,  iodid  of  iron,  etc.,  or  alteratives  and 
general  tonics.  Any  abscess  should  be  freely  opened  as 
early  as  possible ;  and  a  drainage-tube  introduced  or  the 
cavity  packed  with  iodoform  gauze,  and  after  that  washed 
out  at  regular  intervals,  with  hydrogen  dioxid  or  other 
antiseptic.  Dilute  hydrochloric  acid  may  be  injected  in 
the  hope  of  removing  carious  bone  and  stimulating  granu- 
lations. Curetting  the  carious  surface,  or  attempts  to 
remove  necrosed  bone  should  be  deferred  until  the  surgeon 
has  learned  pretty  accurately  the  limits  of  the  disease, 
and  until  a  free  external  opening  is  established. 

^nophthalmos. — Sinking  of  the  eyeball  in  the  orbit, 


472  EXOPHTHALMOS. 

causing  it  to  appear  smaller  than  its  fellow,  occurs  from 
emaciation,  traumatism,  paralysis  of  the  sympathetic,  and 
possibly  other  nerve-lesions. 

Exophthalmic  goiter  (Graves'  or  Basedaw's  disease) 
is  not  essentially  a  disease  of  the  eyes,  but  its  ocular 
symptoms  and  complications  are  of  such  importance  that 
it  very  often  is  brought  to  the  notice  of  the  ophthalmic 
surgeon. 

Symptoms. — Along  with  increased  rapidity  and  irrita- 
bility of  the  heart's  action  and  variable  enlargement  of 
the  thyroid,  there  occurs  exophthalmos,  which  may  reach 
such  high  degree  that  it  is  impossible  for  the  cornea  to 
be  covered  by  the  lids,  and  the  exposed  portion  of  the 
cornea  may  become  vascular,  or  may  ulcerate  or  slough, 
destroying  the  eye.  The  protrusion  of  the  eye  (proptosis), 
however,  often  appears  greater  than  it  really  is,  on  account 
of  the  retraction  of  the  lids.  These  are  habitually 
separated  more  widely  than  normal  (Dalrymple's  sign}. 
They  are  incompletely  closed  in  winking,  and  the  interval 
between  the  attempts  at  winking  is  irregular,  being  some- 
times much  prolonged  (Stellwag's  sign).  On  looking  down- 
ward, the  upper  lid,  instead  of  normally  following  the 
motion  of  the  globe,  remains  more  or  less  elevated  (von 
Graefe's  sign).  Usually  these  symptoms  are  bilateral, 
although  the  exophthalrnos  may  be  greater  on  one  side 
than  on  the  other.  But  they  may  affect  but  one  eye. 

Treatment. — The  general  tonic  treatment  and  regu- 
lated life  which  should  be  carried  out  need  not  here  be 
dwelt  upon.  The  eyes  should  be  studied  as  a  possible 
source  of  nerve-strain,  and  treated  accordingly.  If  the 
exophthalmos  becomes  excessive,  it  may  be  best  for  the 
cosmetic  effect,  or  to  prevent  corneal  disease,  to  try  to 
narrow  the  palpebral  fissure  by  tarsorrhaphy ;  yet  even 
this  may  be  ineffective.  If  sloughing  of  the  cornea 
occurs,  enucleation  may  be  necessary. 

Pulsating  Exophthalmos. — Under  this  title  are 
included  cases  presenting  several  distinct  pathological  con- 
ditions, which  are  best  considered  together,  because  the 
symptoms  they  present  are  so  nearly  indentical  that  in 


DISEASES  OF  THE  ORBIT.  473 

practice  it  may  be  quite  impossible  to  decide  which  con- 
dition is  present. 

Symptoms. — There  is  exophthalmos,  the  eye  being 
displaced  forward  (and  usually  a  little  downward)  some- 
times so  far  that  the  lids  cannot  be  closed  over  it.  Pul- 
sation of  the  orbital  contents  is  sometimes  visible,  and 
always  perceptible  to  touch.  A  decided  bruit  is  present, 
very  annoying  to  the  patient,  and  heard  distinctly  by  the 
surgeon  over  the  orbit  and  the  neighboring  regions  of  the 
skull.  The  eyeball  by  firm  pressure  may  be  restored 
toward  its  normal  position,  but  again  protrudes  when  the 
pressure  is  removed.  These  symptoms  are  relieved  largely 
or  completely  by  pressure  on  the  carotids.  Vision  is  often 
but  moderately  impaired ;  but  some  cases  show  optic 
neuritis,  and  there  may  be  enormous  dilatation  of  the 
veins,  both  of  the  retina  and  orbit.  The  movements  of 
the  eye  are  limited,  the  orbital  muscles  may  be  quite 
paralyzed,  and  the  pupil  widely  dilated.  The  bruit  is 
heard  by  the  patient  as  a  blowing,  puffing,  buzzing,  sing- 
ing, whistling,  roaring  or  hammering  noise,  and  is  often 
accompanied  by  vertigo.  The  lids  and  conjunctiva  are 
often  swollen,  and  show  venous  congestion,  and  the 
cornea  may  become  hazy,  or  ulcerated  from  exposure. 
The  whole  area  supplied  by  the  ophthalmic  branch  of  the 
fifth  nerve  may  be  anesthetic.  A  distinct  soft  pulsating 
tumor  may  sometimes  be  felt  below  the  brow. 

Causes  and  Pathology. — This  condition  has  been 
ascribed  to  aneurism  of  the  ophthalmic  artery,  but  this 
lesion  has  been  found  in  very  few  cases.  The  symptoms 
do  not  occur  with  unruptured  aneurism  of  the  internal 
carotid.  The  most  frequent  lesion  is  a  laceration  of  the 
carotid  artery  within  the  cavernous  sinus.  This  may  be 
due  to  traumatism  causing  fracture  of  the  base  of  the 
skull,  in  which  cases  the  symptoms  develop  rapidly 
within  a  few  weeks  after  the  injury.  It  also  occurs 
spontaneously,  usually  in  elderly  women,  the  symptoms 
developing  quite  suddenly  after  a  feeling  of  something 
having  broken  within  the  head.  In  a  few  cases,  a  vas- 


474  PULSATING  EXOPHTHALMOS. 

cular  tumor  has  been  discovered  in  the  orbit ;  and  in  some 
autopsies  no  significant  lesions  have  been  found. 

Diagnosis. — The  condition  may  be  closely  simulated 
for  a  time  by  a  highly  vascular  malignant  new-growth 
in  the  orbit.  But  the  absence  of  traumatism,  and  the 
gradual  development  of  symptoms,  with  the  attendant 
cachexia,  should  distinguish  the  malignant  disease.  In 
trying  to  fix  the  cause  of  the  particular  case,  the  feeling 
of  something  giving  way,  and  sudden  onset,  or  the  history 
of  injury  with  other  symptoms  of  fracture  of  the  base  of 
the  skull,  characterize  the  arterio-venous  aneurism  of  the 
carotid  and  cavernous  sinus.  In  aneurism  of  the  ophthal- 
mic artery  or  vascular  growths  in  the  orbit  the  develop- 
ment of  symptoms  will  be  more  gradual. 

Treatment  and  Prognosis. — The  course  of  this  disease 
usually  extends  over  several  months  or  years.  A  few 
cases  recover  spontaneously,  more  die  of  rupture  of  the 
arterio-venous  aneurism.  Compression  of  the  carotid 
may  lead  to  cure,  and  should  be  tried  if  practicable.  It 
is  more  likely  to  cure  the  idiopathic  cases,  and  can  some- 
times be  kept  up  by  the  patient  himself.  If  it  fail,  liga- 
tion  of  the  carotid  is  the  most  promising  measure  and 
should  be  tried.  A  vascular  tumor  may  be  treated  by 
excision  or  electrolysis. 

Angiotnata  of  the  orbit  usually  extend  into  the  lids 
(see  page  460). 

Dermoid.  cysts  of  the  orbit  are  congenital,  but  de- 
velop slowly.  They  appear  most  frequently  at  the  inner 
or  outer  upper  margin  of  the  orbit.  They  are  smooth, 
rounded,  elastic,  not  closely  connected  with  the  skin,  but 
usually  with  firm  connection  with  deeper  structures. 
They  may  be  quite  small  and  superficial,  or  may  have 
prolongations  to  the  depths  of  the  orbit,  or  even  beyond. 
Some  idea  of  the  size  of  the  cyst  may  be  obtained  from 
its  behavior  under  pressure.  If  superficial,  it  shows  little 
change  of  size  ;  if  deep,  the  visible  portion  retreats  under 
pressure,  and  the  eyeball  and  other  contents  of  the  orbit 
are  pushed  forward.  Dermoids  require  removal  on 
account  of  their  unsightly  appearance.  If  not  very  deep, 


DISEASES  OF  THE  ORBIT.  475 

they  should  be  excised,  care  being  taken  to  dissect  out 
the  whole  sac,  to  avoid  recurrence.  Very  good  results 
have  been  obtained  by  opening  the  sac,  emptying  it,  and 
placing  in  it  a  few  crystals  of  silver  nitrate,  or  injecting 
tincture  of  iodini 

Other  Cysts. — Encephalocele  is  congenital,  and  ap- 
pears at  the  inner  angle  of  the  orbit.  It  pulsates,  and  is 
reducible  by  pressure  through  passage  of  the  fluid  into 
the  cranium.  It  should  be  let  alone.  The  child  dies  of 
accompanying  cerebral  lesions,  or  of  meningitis  from  in- 
flammation starting  in  the  sac. 

Another  congenital  cyst  is  that  always  associated  with 
extreme  microphthalmus  or  anophthalmus,  and  developed 
from  what  should  have  furnished  the  interior  structure 
of  the  eye.  This  distends  the  lower  lid  and  may  occupy 
the  whole  orbit.  In  addition  there  have  been  found  in 
the  orbit  exudation-cysts  following  hemorrhage,  hydatids 
and  cysticercus. 

Orbital  tumors,  if  at  all  extensive,  cause  protrusion 
of  the  eye,  which,  if  not  too  rapid,  is  accompanied  by 
compensatory  hypertrophy  of  the  lids,  particularly  the 
upper.  Such  a  tumor  is  usually  fixed,  although  the 
movement  of  the  loose  tissues  over  it  often  gives  a  decep- 
tive sense  of  movement  of  the  tumor.  They  may  reach 
a  very  large  size,  and  greatly  displace  the  eyeball,  with- 
out causing  complete  blindness.  Often  the  character  of 
the  growth  can  only  be  recognized  by  microscopical  ex- 
amination. The  question  of  a  syphilitic  origin  should 
always  be  considered,  and  doubtful  cases  submitted  to 
the  test  of  careful  anti-syphilitic  treatment.  Tumors  of 
the  optic  nerve  are  discussed  on  page  390. 

Sarcoma  of  the  several  varieties  occurs  in  the  orbit. 
It  may  start  from  the  walls  of  the  orbit,  or  from  any  of 
its  contents,  or  may  invade  the  orbit  from  neighboring 
cavities.  The  recognized  treatment  is  early  extirpation, 
although  the  growth  is  liable  to  recur.  Generally  the 
whole  of  the  orbital  contents  should  be  removed,  and  if 
the  growth  be  large,  it  will  be  well  on  the  following  day 
to  cauterize  the  orbital  walls  with  chlorid  of  zinc  paste. 


476  ORBITAL  TUMORS. 

The  method  of  Coley  of  injecting  mixed  toxins  is  also 
worthy  of  trial  and  further  development. 

Fibroma  and  fibrosarcoma  also  occur  in  the  orbit. 
Carcinoma  invades  the  orbit  secondarily.  Lymphoid 
growths  (lymphoma)  occur  in  and  about  the  orbit  in  cases 
of  leukemia.  Chloroma,  a  growth  of  a  light  green  color, 
is  also  closely  connected  with  leukemia  though  often 
classed  as  a  sarcoma. 

Osteoma  (ivory  exostosifi)  is  a  hard,  rounded,  firmly- 
fixed,  slowly-growing  tumor,  that  appears  usually  at  the 
upper  inner  angle  of  the  orbit,  somewhat  back  from  the 
margin.  It  causes  no  pain  in  the  early  part  of  its  course, 
and  little  disturbance  of  vision.  The  growth  commonly 
starts  from  the  ethmoid  or  frontal  sinus,  and  may  extend 
toward  the  brain  as  well  as  toward  the  orbit.  It  is 
commonly  attached  by  a  comparatively  narrow  pedicle. 
Early  removal  is  the  best  treatment,  though  this  is 
attended  with  some  risk  if  the  growth  has  extended 
toward  the  brain. 

Hyperostosis. — Excessive  and  irregular  development 
of  bones  of  the  skull  may  cause  distortion,  displacement 
and  great  asymmetry  of  the  orbits. 

Imperfect  development  of  the  orbit  may,  but 
does  not  always,  occur  after  early  enucleation  of  the  eye. 

Disease  of  the  adjoining  cavities,  especially 
malignant  growths  and  empyema,  may  invade  the  orbit. 
Obstruction  of  the  infundibulum  connecting  the  frontal 
sinus  with  the  anterior  cells  of  the  ethmoid,  leads,  accord- 
ing to  the  nature  of  the  secretion,  to  mucocele,  or  to 
empyema  (abscess)  of  the  frontal  sinus.  Such  a  collec- 
tion is  liable  to  make  its  escape  by  working  its  way  into 
the  orbit,  appearing  at  the  upper  inner  angle,  either  as  a 
hard  rounded  tumor,  a  distended  shell  of  bone,  or  as  a 
chronic  abscess,  which,  when  opened,  is  found  to  lead  into 
the  frontal  bone.  Empyema  of  the  frontal  sinus  is  shown 
by  the  interruption  of  transillumination  when  a  small  elec- 
tric light  is  placed  just  below  the  brow  at  the  inner  angle 
of  the  orbit.  It  is  most  common  in  young  adults.  The 
sinus  should  be  opened  from  the  inner  angle  of  the  orbit 


DISEASES  OF  THE  ORBIT.  477 

by  trephining  or  an  osteoplastic  operation,  freely  enough 
to  admit  thorough  exploration  with  the  little  finger,  and 
cleansed  regularly  with  an  antiseptic  solution,  until  it  fills 
from  the  bottom  with  granulation-tissue. 

Diseases  of  the  ethmoid  and  sphenoid  involve  the 
orbit  through  direct  extension.  Polypi  frequently  origi- 
nate in  the  ethmoid,  and,  besides  extending  downward, 
may  cause  the  ethmoidal  wall  of  the  orbit  to  give  way, 
causing  exophthalmos ;  or  through  the  extremely  thin 
walls  of  the  sphenoid,  pressure  may  reach  the  optic  nerve 
in  or  near  the  optic  foramen  and  cause  atrophy.  Optic 
atrophy  in  connection  with  the  dropping  of  watery  fluid 
from  the  nostril  probably  has  some  such  origin.  Caries 
or  necrosis  in  either  of  these  bones  is  liable  to  extend  to 
the  orbit.  Nasal  disease,  and  even  its  active  surgical 
treatment,  have  been  followed  by  optic  neuritis.  The 
nasal  condition  must  receive  appropriate  treatment ;  and 
where  abscess  of  the  orbit  has  in  this  way  arisen,  free 
drainage  should  be  provided  into  the  nose,  as  well  as 
externally. 

Empyema  of  the  maxilliary  antrum  may  also 
open  into  the  orbit.  It  is  revealed  by  transillumination. 
An  electric  light  placed  in  the  mouth  causes  a  red  glow 
in  the  eye,  readily  seen  in  the  pupil,  if  the  intervening 
tissues  be  normal  ;  but  with  pus  in  the  antrum,  this 
transmission  of  light  is  interrupted.  Effective  treatment 
must  include  free  drainage  of  the  antrum,  either  by  a 
large  opening  low  down  into  the  nose,  or  through  the 
canine  fossa. 

BIBLIOGRAPHY. 

Diseases  of  the  Eyelids.     Geo.  C.  Harlan,  "System  of  Diseases  of 

the  Eye,"  vol.  iii ;  B.  L.  Millikin,  "American  Text-book." 
Abnormal  Associated  Movements  of  the  Eyelids.     W.  W.  Sinclair, 

"  Ophthalmic  Review,"  Oct.,  1895. 
Mollusenm  Contagiosum  of  the  Eyelids.     H.  Muetze,  "  Archives  of 

Ophthalmol.,"  Jan.,  1897. 

Chancre  of  the  Eyelids.     David  Debeck,  Cincinnati. 
Sarcoma  of  the  Lid.     W.  H.  Wilmer,  "  Trans.  Amer.  Ophthalmol. 

Soc.,"  1894. 
Necrosis  of  the  Skin  of  the  Eyelids.     C.  J.  Kipp,  ''  Trans.  Amer. 

Ophthalmol.  Soc.,"  1896. 


478  BIBLIOGRAPHY. 

Facial  Spasm  and  Associated  Refraction.     E.  W.  Stevens,  "Trans. 

Colo.  State  Med.  Soc.,"  1899. 

Pediculi  Ciliaris.     P.  N.   K.  Schwenk,  "Wills'  Eye  Hospital  Re- 
ports," 1895. 
Chronic  Enlargement  of  Lacrymal  and  Salivary  Glands.  Wm.  Osier, 

"  Amer.  Jour,  of  the  Med.  Sciences,"  Jan.,  1898. 
Dacryoadenitis.     R.  L.  Randolph,   "Archives  of  Ophthalmology," 

Jan.,  1897. 
Sarcoma  of  the  Lacrymal  Gland.     J.  B.  Lawford  and  E.  T.  Collins, 

"  Roy.  London  Oph.  Hosp.  Rep.,"  vol.  xiii,  pt.  iv. 
Mycosis  of  the   Inferior   Canaliculus.     John  Dunn,  "Archives  of 

Ophthalmol.,"  April,  1897. 
Operation   for  Stricture   of  the   Lacrymal  Duct.     C.   H.   Thomas, 

"Trans.  Sect,  on  Ophthalmol.,  Amer.  Med.  Assoc.,"  1892. 
Diseases  of  the  Lacrymal  Apparatus.     S.  Theobald,  "Amer.  Text- 
„         book  "  and  "  System  of  Dis.  of  the  Eye,"  vol.  iii. 
Large  Probes  in  the  Treatment  of  Lacrymal  Obstruction.     S.  Snell, 

"Ophthal.   Review,"   Apr.,   1895;    "Trans.   Eighth    Internat. 

Oph.  Congress." 
Extirpation   of   the   Lacrymal   Sac  and   Gland.      C.   R.    Holmes, 

"Archives  of  Ophthalmol.,"  Jan.,  1899. 
Diseases  of  the  Orbit.     C.  S.  Bull,  "  System  of  Diseases  of  the  Eye," 

vol.  iii;  F.  Buller,  "American  Text-book." 
Lipoma  of  the  Orbit.     E.  Gruening,  "Trans.  Amer.  Ophthal  Soc.," 

1898. 
Acute  Exophthalmic  Goitre.     J.  Griffith,  "Ophthalmic  Review," 

July,  1898. 
Extirpation  of  the  Cervical  Sympathetic  for  Exophthalmic  Goitre. 

T.  Jonnesco,  "Ophthalmic  Review,"  April,  1897. 
Plastic   Cellulitis   of  the   Orbit.     Geo.    Lawson,    "  Trans.  Ophthal. 

Soc.  of  the  United  Kingdom,"  Dec.,  1894. 
Spontaneous  Orbital   Hemorrhage.      C.    E.    Finlay.   "  Archives  of 

Ophthalmol.,"  Jan.,  1897. 
Treatment   of  Dermoid   Tumors   of  the   Orbit.     F.  Buller,  "  Trans. 

Amer.  Ophthalmol.  Soc.,"  1896. 
Cavernous  Lymphangioma  of  the  Orbit.     S.  C.  Ayres,  "Trans.  Sec. 

on  Ophthalmol. ,  Med.  Amer.  Assoc.,"  1895;  ''Ophthalmic  Re- 
view," Apr.,  1896. 
Chloroma.     S.    C.  Ayres,   "Amer.    Jour,    of  Ophthalmol.,"    Mar., 

1897  ;  "  Ophthalmic  Review,"  Mar.,  1897. 
Bony   Tumors   of  the   Orbit.     Mitvalsky,    "Ophthalmic   Review," 

Feb.,  1895. 
Hyperostosis  of  the  Cranium.     J.  J.  Putnam,  "Amer.  Jour,  of  the 

Medical  Sciences,"  July,  1896. 
Operative  Treatment  of  Lesions  of  the  Frontal  Sinus.     S.  S.  Golo- 

vine,  "Arch,  of  Ophthalmol.,"  May,  1898. 
The  Sphenoidal  Cavity  and  Its  Relations  to  the  Eye.     C.  R.  Holmes, 

"Arch,  of  Ophthalmology,"  Oct.,  1896. 


MECHANICAL  INJURIES.  479 


CHAPTER  XVII. 

MECHANICAL    INJURIES     OF    THE    EYE"  AND    ITS 
APPENDAGES. 

CONTUSIONS. 

THE  lids  with  their  loose  cellular  tissue  permit  free 
extravasation,  and  free  diffusion  of  the  blood  which  is 
extravasated. 

Hence  bruise  of  the  lids  is  likely  to  be  followed  by 
very  noticeable  ecchymosis  and  much  swelling.  The 
swelling  comes  and  goes  rapidly.  The  discoloration  takes 
one  or  more  weeks  to  disappear.  The  lids  also  become 
discolored  from  hemorrhage  attending  injuries  to  the 
bones  of  the  orbit,  or  the  base  of  the  skull.  With  such 
injuries,  the  discoloration  appears  many  hours  or  days 
after  the  injury,  and  then  not  at  the  point  of  impact  but 
at  the  part  of  the  lids  just  within  the  margin  of  the  orbit. 

In  bruise  of  the  lids  extravasation  is  checked  by  the 
immediate  application  of  pressure.  The  traditional  beef- 
steak, with  its  astringent  albuminous  juices,  offers  an 
excellent  method.  Equally  efficacious  is  the  prompt 
application  of  cold,  as  by  an  ice-compress.  The  benefit 
of  cold  ceases  with  the  period  of  extravasation.  After 
that,  pressure,  and  later  occasional  hot  fomentations,  and 
massage,  are  indicated. 

Heavy  contusions  about  the  head  are  liable  to  cause 
fracture  of  the  bones  of  the  orbit,  with  important 
effects  on  the  eye  and  its  appendages.  Fracture  of  bones 
enclosing  air  spaces  connected  with  the  respiratory  tract 
may  admit  air  to  the  cellular  tissue,  causing  emphysema 
(see  page  459).  Blows  on  the  brow  or  the  frontal  and  malar 
eminences  are  transmitted  to  the  sphenoid,  where  their 
force  may  cause  fracture  involving  the  optic  foramen,  and 
immediate  blindness,  from  laceration  or  compression  of 
the  optic  nerve.  At  first  the  ophthalmoscopic  appearances 
may  be  normal,  but  in  a  few  weeks  white  atrophy  of  the 
optic  nerve  appears ;  and  from  the  first  the  pupil  responds 


480          FRACTURE  OF  BONES  OF  THE  ORBIT. 

imperfectly  or  not  at  all  to  light  thrown  into  the  affected 
eye. 

Paralysis  of  other  cranial  nerves  may  follow  fractures 
of  the  base  of  the  skull,  either  at  once  from  laceration  or 
hemorrhage,  or  gradually  after  several  days  from  pressure 
by  exudate  or  callus.  The  abducens  is  by  far  the  most 
frequently  affected,  the  paralysis  being  often  bilateral. 

Dislocation  of  the  eyeball  may  be  produced  by 
certain  contusions,  as  by  the  horn  of  a  cow.  The  globe 
has  thus  been  pushed  out  so  that  the  lids  fell  behind  it, 
or  has  been  thrust  into  the  nasal  cavity  or  maxillary 
antrum.  Fracture  of  the  walls  of  the  orbit  thrusting  them 
outward,  or  atrophy  of  orbital  tissue  following  injury, 
have  caused  enophthalmos  (see  page  471).  Fracture  of  the 
walls  of  the  orbit,  thrusting  them  in,  emphysema,  hemor- 
rhage, inflammatory  exudate,  or  the  palsies  of  the  ocular 
muscles  cause  exophthalfnos.  Traumatic  pulsating  exoph- 
thalmos  is  elsewhere  described  (page  472).  Traumatic  dis- 
location of  the  lacrimal  gland  into  the  lid  has  occurred. 

Rupture  of  the  eyeball  is  caused  by  blows  like  that 
of  the  fist.  It  is  commonly  located  a  little  back  of  the 
upper  inner  part  of  the  corneal  margin,  and  parallel  with  it. 
Often  the  crystalline  lens,  and  sometimes  also  the  iris,  is 
dislocated  through  the  rupture,  beneath  the  conjunctiva. 
The  line  of  rupture  appears  somewhat  irregular,  and  dark 
with  incarcerated  uveal  pigment.  The  lens  is  at  first 
yellowish,  becoming  whiter  and  shrunken  with  the  lapse 
of  time.  The  iris  if  not  torn  from  its  attachment  falls 
back  from  the  cornea,  especially  in  the  direction  of  the 
rupture,  where  it  may  be  folded  under  so  as  to  be  entirely 
concealed.  The  softness  of  the  eyeball  immediately  after 
injury  will  reveal  the  existence  of  a  rupture,  if  located  so 
far  back  that  it  cannot  be  seen. 

After  recent  rupture,  the  prolapsed  lens  or  iris  should 
be  removed  from  beneath  the  conjunctiva,  and  the  edges 
of  the  rupture  drawn  together  with  fine  sutures.  Usually 
the  injuries  to  the  interior  of  the  eye  are  so  great  as  to 
make  the  eye  useless ;  but  a  few  cases  recover  with  use- 
ful sight  by  the  aid  of  lenses. 


MECHANICAL  INJURIES.  481 

Contusion  of  the  eyeball  not  powerful  enough  to 
cause  rupture  of  the  sclera  occurs  from  a  blow  with  a 
small  stone,  a  marble,  the  cork  of  a  champagne  bottle,  or 
the  knot  on  the  end  of  a  whip-lash.  It  may  cause  con- 
junctival  ecchymosis,  rarely  a  small  superficial  slough 
and  ulcer  of  the  cornea,  and  often  serious  damage  to  struc- 
tures within  the  sclerocorneal  coat. 

Rupture  of  the  iris  from  contusion  of  the  eyeball  is 
not  rare.  It  may  occur  at  the  ciliary  border,  iridodialysis, 
causing  a  false  pupil  behind  the  margin  of  the  cornea, 
and  a  flattening  of  the  side  of  the  normal  pupil  toward  it, 
as  shown  in  Fig.  143.  Radiating  ruptures  of  the  iris  also 
occur.  They  may  appear  either  as  nicks  in  the  margin 
of  the  pupil,  rupture  of  the  sphincter,  or  fissures  in  the 
substance  of  the  iris.  These  are  shown  in  Fig.  144.  Such 


FIG.  143.— Iridodialysis,  tearing  of  iris  from  its  ciliary  attachment,  making 
a  false  pupil,  through  which  is  seen  the  lens-margin,  and  causing  flattening 
of  the  true  pupil.  Ophthalmoscopic  illumination. 

FIG.  144.— Multiple  ruptures  of  the  iris.  Tears  in  the  sphincter,  and  separa- 
tion of  the  radiating  iris-fibers. 

lesions  are  attended  with  hemorrhage  into  the  anterior 
chamber,  hyphemia  (page  408)  which  may  for  a  time  conceal 
them  or  may  call  attention  to  a  rupture  so  small  as  other- 
wise to  be  overlooked.  Such  hemorrhage  is  commonly 
entirely  absorbed  in  two  or  three  days,  but  it  may  recur. 

Paralysis  of  the  iris-sphincter  (traumatic  irido- 
pfagia)  without  rupture  may  occur  from  stretching.  The 
pupil  is  found  partly  dilated  and  sluggish.  It  usually 
regains  its  power  in  a  few  days  or  weeks.  Permanent 
dilatation  is  more  apt  to  depend  on  slight  rupture. 

Traumatic  cycloplegia,  paralysis  of  accommoda- 
tion from  injury  to  the  ciliary  body,  may  also  occur,  caus- 
ing imperfect  vision  from  inability  to  focus  near  objects. 
31 


482  CONTUSIONS  OF  THE  EYEBALL. 

A  temporary  astigmatism  may  arise  from  injury  to  the 
same  part. 

There  may  also  be  hemorrhage  into  the  vitreous, 
causing  complete  loss  of  sight  until  it  is  removed  by 
absorption. 

The  treatment  for  such  injuries  by  contusion,  is  at 
first  complete  rest  of  the  eye,  under  a  mydriatic,  with  the 
application  of  cold  if  there  are  signs  of  violent  reaction. 
After  all  symptoms  of  inflammation  have  subsided,  it 
may  be  well  to  try  the  effect  of  a  myotic  if  the  pupil 
remains  dilated.  When  iridodialysis  causes  diplopia  or 
annoying  diffusion,  an  incision  may  be  made  in  the  ex- 
treme periphery  of  the  cornea  opposite  the  center  of  the 
separation,  and  the  edge  of  the  iris  drawn  into  it  and 
incarcerated  or  fastened  with  a  stitch ;  or  the  detached 
portion  of  the  iris  may  be  removed  by  iridectomy.  Such 
injuries  to  the  iris  often  permanently  impair  vision. 

Injuries  Of  the  lens  by  contusion  of  the  globe  in- 
clude traumatic  cataract  and  dislocation  of  the  lens. 
The  former  is  caused  by  rupture  of  the  lens-capsule  and 
differs  little  from  that  caused  by  penetrating  wounds. 
Dislocation  of  the  lens  (see  page  424)  may  be  into  the  ante- 
rior chamber  (Fig.  145).  More  commonly  it  is  backward, 


FIG.  145.— Dislocation  of  the  clear,  lens  into  the  anterior  chamber.    Iris  and 
pupil  seen  through  the  lens.    Pericorneal  hyperemia. 

and  still  more  frequently  it  is  only  partial,  the  lens  tilting 
back  at  some  part  of  the  circumference,  causing  myopia 
and  astigmatism  by  its  increased  curvature  and  oblique 
position.  These  results  may  be  permanent  or  there  may 
be  considerable  recovery.  Such  injuries  should  be  treated 
by  the  early  application  of  cold  to  diminish  reaction, 
rest,  and  usually  the  placing  of  the  eye  under  a  mydriatic. 


MECHANICAL  INJURIES. 


483 


Later  a  myotic  may  be  beneficial,  and  the  measures  indi- 
cated on  page  425  become  appropriate. 

Traumatic  Kdema  of  the  Retina  (Commotio  Re- 
tince). — Bruise  of  the  eyeball  is  sometimes  followed  by 
temporary  impairment  of  sight  without  any  external  evi- 
dence of  injury.  But  the  ophthalmoscope  shows  in  the 
first  few  hours  a  diffuse  gray  haziness  or  more  dense 
opacity  of  the  retina  at  the  posterior  pole  of  the  eye, 
probably  due  to  edema.  This  haziness  soon  begins  to 


FIG.  146. — Traumatic  edema  of  retina  and  choroid,  four  hours  after  contusion 
of  the  right  eye.    The  dark  spot  is  the  center  of  the  macula. 

diminish  and  passes  off  entirely  in  from  two  to  four  days. 
It  is  often  associated  with  slight  lesions  of  the  choroid, 
which  remain  visible  longer.  After  disappearance  of  the 
retinal  opacity,  the  vision  is  soon  restored  to  normal. 
Rest  of  the  eyes,  with  guarding  against  excessive  light  is 
all  the  treatment  required. 

Injuries  of  the  Choroid. — With  the  changes  of  the 
retina  above  described,  there  often  occur  small  patches 
of  light,  yellowish,  swollen  choroid,  which  may  be 


484 


INJURIES  OF  THE  CHOROID. 


arranged  in  something  of  an  arc  or  crescent  concentric 
with  the  optic  disk.  These,  if  not  attended  with  hemor- 
rhage, fade  gradually  away  after  a  few  days,  the  fundus 
becoming  quite  normal  in  appearance.  But  if  the  injury 
has  been  more  severe,  the  patches  may  run  together  form- 
ing one  or  more  light  crescents,  or  these  may  for  a  time 
be  concealed  by  hemorrhage  into  the  vitreous.  A  few 
weeks  later,  when  the  hemorrhage  has  been  absorbed,  the 


FIG.   147.— Rupture  of  the  choroid,  right  eye,  from   contusion   by  a  small 
stone.    The  "  rupture  "  lies  between  the  disk  and  the  macula. 

crescent  is  found  to  be  a  choroidal  atrophy  with  massing 
of  pigment  along  its  borders.  Often  there  are  also  in- 
complete choroidal  atrophies  in  other  parts  of  the  fundus. 
This  is  the  appearance  known  as  rnj>fit>r  of  the  choroid 
and  illustrated  in  Fig.  147.  The  retinal  vessels  are  seen 
to  cross  the  atrophic  area  uninjured.  The  lesion  is  prob- 
ably an  atrophy  following  injury  and  partial  rupture  of 
the  tissue  of  the  choroid.  Its  striking  curved  form, 


MECHANICAL  INJURIES.  485 

usually  roughly  concentric  with  the  optic  disk,  may  be 
due  to  a  sharp  bending  of  the  coats  of  the  eye  occurring 
along  this  line,  when  the  globe  is  forced  back  against  the 
support  given  by  the  optic  nerve.  In  severe  injuries, 
effused  blood  may  pass  behind  the  choroid  detaching  it 
from  the  sclera. 

Treatment  is  similar  to  that  of  other  contusion-lesions 
within  the  globe — rest  under  a  mydriatic.  After  the 
slight  lesions,  recovery  may  be  complete.  But  "  rupture  " 
is  usually  attended  with  marked  permanent  impairment 
of  vision. 

In  rare  cases  optic  neutritis  or  atrophy  may  be  due  to 
force  transmitted  to  the  nerve  from  bruise  of  the  eyeball 
or  other  contents  of  the  orbit. 


WOUNDS  WITHOUT  LODGEMENT  OF  FOREIGN  BODIES. 

Although  it  is  convenient  to  consider  apart  wounds 
complicated  by  the  lodgement  of  a  foreign  body,  it  is  best 
to  regard  every  case  of  traumatism  as  possibly  compli- 
cated in  this  way,  until  investigation  reveals  the  contrary. 
The  question  of  probable  infection  must  also  be  con- 
sidered in  every  case,  and  the  effort  made  to  render  the 
wound  aseptic.  In  doing  this  it  must  be  remembered 
that  hemorrhage  is  a  guard  against  sepsis,  and  should  not 
be  checked  too  promptly,  nor  should  effused  blood  be  too 
industriously  diluted  and  washed  away  by  watery  solu- 
tions. 

Wounds  of  the  lids,  on  account  of  the  vascularity 
of  the  parts,  unite  early.  But  because  of  the  looseness 
of  the  tissues  involved,  the  lips  of  the  wound  are  very 
liable  to  be  displaced  ;  and  if  they  unite  thus,  a  permanent 
deformity  is  caused.  On  this  account  it  is  extremely  ,. 
important  that  the  parts  should  be  at  once  brought  into 
proper  apposition,  and  permanently  fixed  by  a  sufficient 
number  of  well-placed  sutures.  Any  delay  about  doing 
this  is  especially  harmful,  increasing  the  amount  of  scar- 
tissue,  where  for  cosmetic  reasons,  as  well  as  the  future 
flexibility  and  usefulness  of  the  part,  it  is  especially 


486  WOUNDS  OF  THE  LIDS. 

important  to  reduce  the  scar-tissue  to  a  minimum. 
When  there  is  absolute  loss  of  tissue,  it  is  better  to  re- 
place this  by  drawing  in  neighboring  tissue  by  some 
plastic  operation  than  to  trust  to  its  replacement  by 
granulation-tissue. 

The  resulting  deformity  is  least  when  the  wound  lies 
parallel  to  the  fibers  of  the  orbicularis  muscle.  It  is 
likely  to  be  greatest  and  most  difficult  to  prevent  when 
the  wound  extends  through  the  free  edge  of  the  lid.  In 
some  of  these  cases  a  fine  straight  needle  and  harelip- 
suture  may  give  the  best  result.  Care  should  be  taken 
to  secure  cleanliness  of  the  surfaces  brought  together,  and 
inflammatory  swelling  must  be  kept  down  by  the  con- 
tinous  application  of  cold.  The  stitches  should  be  care- 
fully placed,  including  the  depth  of  the  tissues.  They 
may  be  inspected  each  day,  and  any  that  show  evidences 
of  stitch-hole  abscesses,. removed  early.  But  some  must 
remain  until  the  swelling  subsides  and  union  is  likely  to 
be  firm.  If  the  stitches  are  withdrawn  early,  the  parts 
must  be  supported  and  protected  by  properly  placed  strips 
of  adhesive  plaster.  The  same  dressings  are  to  be  em- 
ployed as  after  operations  on  the  lids  (see  Chapter  XIX). 

Wounds  in  certain  regions  require  special  care.  Thus 
the  division  of  a  canaliculus  generally  makes  it  necessary 
to  slit  both  portions  to  prevent  obstruction  to  the  flow  of 
tears.  A  wound  of  the  upper  lid  may  divide  the  tendon 
of  the  elevator  muscle,  in  which  case  the  divided  ends 
must  be  searched  for,  and  united  to  prevent  permanent 
ptosis.  Deformity  of  the  lids  caused  by  old  scars  can 
sometimes  be  lessened  by  prolonged  massage  ;  but  may 
require  some  of  the  most  delicate  and  difficult  of  plastic 
operations.  Swelling  of  the  lids  should  never  prevent 
careful  search  for  accompanying  lesions  of  the  eyeball. 

Penetrating  wounds  of  the  orbit  are  usually  deep 
in  comparison  with  their  extent  on  the  surface.  They 
are,  therefore,  especially  liable  to  hide  foreign  bodies,  dif- 
ficult to  thoroughly  cleanse,  and  uncertain  as  to  the 
structures  involved.  They  may  even  be  entirely  con- 
cealed, or  easily  overlooked  on  account  of  the  swelling  of 


MECHANICAL  INJURIES.  487 

superficial  structures.  Injury  of  the  optic  nerve  will 
cause  instant  blindness.  Injury  to  a  muscle  causes 
impairment  of  function  that  may  only  be  discovered 
later.  Hemorrhage,  or  emphysema  produces  exophthalmos, 
which,  from  the  latter  cause,  is  reducible  by  pressure. 

In  the  treatment  of  such  wounds,  the  removal  of  any 
foreign  body,  cold  to  keep  down  swelling,  asepsis,  and 
drainage  are  the  important  points.  Shortly  after  injury, 
the  wound  should  be  washed  out  with  warm  boric  acid 
or  salt  solution.  Later,  hydrogen  dioxid  should  be  em- 
ployed. If  there  is  tendency  to  the  formation  of  a  sinus, 
a  drainage-tube  should  be  introduced,  or  the  wound 
packed  with  iodoform  gauze. 

Wounds  of  the  conjunctiva  only  usually  require 
cleansing,  the  replacing  of  any  flap  in  normal  position, 
and  closing  of  the  eye  for  one  or  two  days  until  union 
can  occur.  Very  extensive  division  and  separation  of  the 
membrane  may  require  sutures.  They  should  be  fine  and 
removed  by  the  third  or  fourth  day. 

Wounds  of  the  Cornea. — Even  slight  abrasions  of 
the  cornea,  such  as  are  often  made  by  the  finger-nail  of 
an  infant,  may  cause  extreme  pain,  with  photophobia  and 
inability  to  use  the  eyes.  The  cornea  is  particularly 
liable  to  infection ;  so  that  all  corneal  wounds  should  be 
closely  watched  until  the  surface  is  again  covered  with 
epithelium.  Even  after  this,  an  erosion  may  recur  with- 
out evident  cause.  Corneal  injuries  are  particularly  dan- 
gerous in  the  presence  of  lacrimal  obstruction. 

On  account  of  the  rigidity  of  the  cornea,  there  is  very 
little  tendency  to  displacement  of  the  parts ;  so  that  even 
extensive  irregular  wounds  very  rarely  require  suture. 
Deep  wounds  always  leave  some  permanent  impairment 
of  transparency,  although  this  may  be  slight,  and  if  not 
in  front  of  the  pupil,  of  no  importance.  When  the  wound 
extends  into  the  anterior  chamber,  the  escape  of  aqueous 
humor  causes  the  loss  of  the  normal  tension  of  the  globe,  and 
abolition  of  the  anterior  chamber.  Wounds  of  the  cornea 
involving  deeper  structures  are  chiefly  of  importance  in 
that  connection. 


488  WOUNDS  OF  THE  CORNEA. 

The  treatment  must  include  careful  cleansing,  repeated 
daily,  the  instillation  of  a  mydriatic,  protection  of  the 
eye  by  a  light  dressing,  to  prevent  the  entrance  of  par- 
ticles of  dust  which  tend  to  lodge  in  the  wound  ;  and  if 
this  is  of  some  length  and  extends  through  the  cornea,  com- 
plete rest  of  the  eyes,  and  even  rest  in  bed,  until  union 
has  occurred.  Cold  applications  should  be  used  with 
caution. 

Wounds  of  the  sclera,  if  they  do  not  perforate  it, 
require  simply  cleansing,  and  heal  quickly.  If  they  ex- 
tend through  the  whole  thickness,  they  cause  diminished 
tension  of  the  eyeball,  and  danger  of  infection  of  the 
vitreous.  All  structures  prolapsing  into  the  wound  should 
be  excised.  The  wound  must  be  carefully  cleansed,  and 
if  extensive,  closed  with  one  or  more  fine  sutures.  Cold 
may  be  used  for  the  first  day  or  two,  to  keep  down  reac- 
tion ;  and  the  eye  should  be  kept  at  rest  under  a  mydriatic 
until  repair  is  well  started.  Very  extensive  wounds  of 
the  sclera  may  still  allow  recovery  of  the  eye,  even  with 
useful  vision.  When,  however,  from  the  general  disor- 
ganization of  the  eye,  or  the  commencement  of  irido- 
cyclitis,  it  becomes  certain  that  only  a  sightless  and 
disorganized  globe  can  remain,  it  will  greatly  shorten  the 
period  of  disability,  as  well  as  remove  the  danger  of 
sympathetic  ophthalmitis,  to  promptly  enucleate  the  in- 
jured organ. 

Wounds  into  the  ciliary  body  are  regarded  as 
especially  dangerous.  The  prolapse  of  the  ciliary  body 
into  the  wound  is  likely  to  interfere  with  drainage, 
and  consequent  swelling  of  the  lens  may  increase  the 
obstruction,  and  infection  is  especially  liable  to  occur. 
Especial  care  must,  therefore,  be  taken  to  remove  all 
prolapsed  or  injured  tissue,  even  though  this  necessitates 
enlarging  the  original  wound. 

Wounds  Involving  the  Iris. — That  a  penetrating 
wound  involves  the  iris  may  be  suspected  from  the  pres- 
ence of  blood  in  the  anterior  chamber ;  or  recognized  by 
distortion  of  the  pupil,  or  the  existence  of  a  second  opening 
in  the  iris.  Prolapse  of  the  iris  into  a  corneal  wound 


MECHANICAL  INJURIES.  489 

appears  as  a  rounded  dark  brown  tumor,  at  the  site  of  the 
wound,  while  the  pupil  is  found  distorted,  and  the  iris- 
tissue  dragged  in  the  direction  of  the  prolapse.  The  pro- 
truding iris  is  at  first  readily  distensible  by  the  escaping 
aqueous,  and  may  appear  to  include  more  of  the  iris  than 
it  really  does,  and  may  vary  in  size  from  day  to  day.  It 
soon  becomes  covered  with  a  layer  of  gray  translucent 
lymph,  and  then  slowly  flattens  down  to  an  adherent 
leucoma,  unless  it  be  quite  extensive  or  the  surrounding 
cornea  softens,  in  which  case  more  iris  may  be  drawn  in, 
and  anterior  staphyloma  develop. 

Treatment. — Simple  incision  of  the  iris,  or  clean 
removal  of  a  part  of  it,  is  generally  not  followed  by 
excessive  reaction,  or  prolonged  healing.  When,  however, 
the  iris  prolapses  into  a  corneal  or  scleral  wound  the  case 
is  more  serious.  In  a  few  cases  of  prolapse  into  small 
corneal  wounds,  the  iris  may  be  pushed  back  into  position 
and  the  prolapse  not  recur.  Cases  of  prolapse  near  the 
periphery  may  be  left  to  flatten  down  without  further 
trouble.  But  in  all  cases  of  large  prolapse  near  the 
center  of  the  cornea,  or  of  probable  infection  of  the  pro- 
truding iris,  that  are  seen  within  the  first  day  or  two,  the 
protruding  portion  should  be  cut  off,  and  the  stump  freed 
as  far  as  possible  from  its  adhesions  to  the  cornea.  From 
about  the  third  to  the  tenth  day  it  may  be  best  not  to 
excise  a  prolapse  of  the  iris,  because  of  increased  risk  of 
general  infection  of  the  eye.  After  the  tenth  day  the 
excision  of  the  prolapse  should  be  done  if  it  seems  to  be 
extending.  Prolapse  of  the  iris  greatly  retards  the  com- 
plete healing  of  the  wound,  a  large  prolapse  taking  six  or 
eight  weeks  to  flatten  down. 

Wounds  of  the  iris  are  to  be  treated  with  rest  and 
mydriatics  until  the  eye  is  free  from  redness  and  irrita- 
bility. At  first  cold  may  be  used  to  lessen  the  reaction, 
if  it  does  not  injuriously  influence  the  cornea.  The  eye 
should  be  kept  closed  with  a  light  dressing  (see  Chapter 
XIX)  until  the  corneal  wound  is  well  united,  or  the 
prolapse  is  flattening  down. 

Wounds  of  the   lens   cause    swelling  and   opacity 


490  TRAUMATIC  CATARACT. 

which  generally  goes  on  to  traumatic  cataract,  and  in 
young  persons  may  be  followed  by  complete  absorption 
of  the  lens.  The  opacity  may  be  noticed  with  the  oph- 
thalmoscope, or  by  oblique  illumination,  immediately  after 
the  injury.  It  begins  at  the  wound,  and  extends  with  a 
rapidity  proportioned  to  the  size  of  the  opening  in  the 
lens-capsule.  If  this  is  large  the  whole  lens  may  become 
hazy  in  a  few  hours.  (See  Fig.  148.)  If  the  progress  is 


FIG.  148. — Traumatic  cataract,  commencing,  after  wound  of  lens,  with  small 
prolapse  of  iris. 

slower  the  opacity  may  assume  a  somewhat  stellate  form, 
closely  resembling  posterior  polar  cataract.  (See  Fig.  130.) 
When  the  wound  in  the  capsule  is  quite  small  it  may  en- 
tirely close,  and  the  opacity  disappear,  or  remain  perma- 
nently confined  to  the  immediate  seat  of  injury.  Some- 
times the  haziness  of  the  lens  becomes  general  immediately 
after  the  injury,  then  in  a  few  weeks  clears  up  to  a  great 
extent,  but  several  months  later  the  lens  slowly  becomes 
entirely  opaque. 

When  the  opening  in  the  capsule  is  large,  the  swelling 
of  the  lens  pushes  out  fragments  of  the  cortex  or  even  the 
whole  nucleus.  These  lie  in  the  angle  of  the  anterior 
chamber  until  dissolved  and  absorbed.  They  usually 
cause  pericorneal  redness,  pain,  photophobia,  and  may 
even  occasion  iridocyclitis  and  loss  of  the  eye. 

Treatment. — The  eye  should  immediately  be  placed 
under  atropin,  with  rest  and  protection  from  excess  of 
light.  If  the  wound  is  minute,  this  gives  the  best  chance 
of  healing  without  causing  general  opacity  ;  and  the  com- 
plete inaction  of  the  ciliary  muscle  must  be  thus  main- 
tained for  many  weeks.  If  the  swelling  of  the  lens  is 
great,  and  the  eye  shows  signs  of  irritation,  the  lens,  or 
at  least  the  nucleus  and  greater  part  of  the  cortex,  should 


MECHANICAL  INJURIES.  491 

be  extracted.  If  the  patient  is  young  and  the  lens-changes 
cause  no  serious  disturbance,  they  may  be  allowed  to  pro- 
ceed without  interference  until  absorption  is  complete ; 
or  if  it  cease,  one  or  more  needle-operations  may  be  done 
to  renew  the  process  until  the  pupil  is  clear.  If  the 
wound  is  through  the  ciliary  region  it  will  be  best  to 
enlarge  it  and  remove  the  lens  with  other  injured  tissues 
without  delay.  After  removal  of  the  crystalline,  a  cor- 
recting lens  will  be  required  for  distant  vision ;  but 
usually  it  will  be  impracticable  to  employ  the  eye  along 
with  the  other  if  it  has  good  vision. 

Wounds  involving1  the  vitreous  are  of  importance 
chiefly  on  account  of  their  liability  to  infection,  which 
will  be  considered  in  connection  with  the  lodgement  of 
foreign  bodies. 


FOREIGN  BODIES  IN  THE  EYE  AND  ORBIT. 

The  possible  lodgement  of  a  foreign  body  should  be 
considered  in  connection  with  every  penetrating  wound 
of  the  eye  or  its  related  structures.  Their  removal  is 
necessary  to  recovery,  and  their  presence  is  liable  to  be 
quite  overlooked.  They  are  searched  for  in  the  same 
general  way  as  foreign  bodies  imbedded  in  other  parts  of 
the  body. 

For  pieces  of  metal  and  glass,  that  are  not  too  minute, 
the  Rontgen  or  x-rays  afford  very  valuable  assistance. 
The  importance  of  locating  a  foreign  body  exactly  has  led 
to  the  taking  of  radiographs,  from  different  directions; 
and  the  use  of  a  metal  indicator  (method  of  Sweet)  placed 
at  a  known  position  in  front  of  the  eye,  with  the  radio- 
graph of  which  that  of  the  foreign  body  can  be  accurately 
compared.  To  get  the  best  results,  a  current  of  high  ten- 
sion must  be  used  allowing  a  short  exposure ;  and  the 
patient  should  be  placed  in  a  comfortable  attitude,  (best 
lying  down),  to  lessen  the  blurring  due  to  slight  changes 
of  position.  The  sensitive  plate  is  bound  to  the  temple 
next  the  injured  eye,  and  the  tube  placed  on  the  opposite 
side  of  the  head  and  rather  in  front.  To  locate  foreign 


492  USE  OF  RONTGEN  RAYS.. 

bodies  in  the  orbit,  bits  of  lead  may  be  fastened  to  the 
skin  at  known  points  on  the  orbital  margin  to  give  points 
for  comparison. 

I/ids  and  Orbit. — The  swelling  of  the  lids  after  in- 
jury readily  conceals  any  foreign  body  lodged  in  a  wound 
made  in  or  through  them ;  hence  in  every  case,  the 
depth  of  the  wound  should  be  carefully  examined,  enlarg- 
ing it  if  necessary  to  admit  the  little  finger  for  the  pur- 
pose. Very  large  foreign  bodies  have  been  extracted 
from  the  orbit,  or  from  the  maxillary  antrum,  nose,  or 
brain-cavity,  into  which  they  had  passed  through  the  orbit, 
when  the  history  of  the  case,  or  the  previous  examina- 
tions by  other  surgeons,  had  given  no  indication  of  their 
presence.  When  found  a  foreign  body  must  be  removed. 
Especial  care  should  be  taken  to  secure  very  free  drainage, 
if  there  is  any  suspicion  of  penetration  of  the  cranial 
cavity. 

Powder-grains  are  liable  to  be  lodged  by  accidental 
explosions  in  the  lids,  conjunctiva,  cornea,  or  sclera. 
The  potassium  nitrate  and  sulphur  of  the  grain  are 
quickly  removed,  causing  a  temporary  inflammation ; 
while  the  fine  particles  of  charcoal  become  gradually 
diifused  through  the  neighboring  tissues,  causing  a  perma- 
nent bluish  stain.  Removal  of  the  grains  should  be 
effected  as  quickly  as  possible.  The  more  superficial 
may  be  removed  by  thorough  scrubbing.  The  deep 
grains  should  be  touched  with  the  galvano-cautery,  which 
causes  the  separation  of  a  slough  in  which  the  particles 
of  carbon  are  imbedded.  These  procedures  may  be  car- 
ried out  under  local  infiltration-anesthesia,  if  the  grains 
are  few,  but  if  the  grains  are  numerous,  they  require 
anesthesia  by  chloroform. 

Foreign  Bodies  in  the  Conjunctiva. — These  have 
direct  access  only  to  the  part  of  the  conjunctiva  exposed  be- 
tween the  lids  on  either  side  of  the  cornea ;  but  they  are 
liable  to  be  carried  by  the  rubbing  of  the  lids  on  the  eye- 
ball into  other  portions  of  the  conjunctival  sac.  Most  fre- 
quently small  particles  will  be  found  to  rest  on  the  surface 
of  the  upper  lid,  about  the  middle  of  the  upper  border 


MECHANICAL  INJURIES.  493 

of  the  tarsal  cartilage,  as  illustrated  in  Fig.  149.  But 
they  may  become  lodged  in  other  portions,  especially  in 
the  retrotarsal  folds;  and  if  retained  many  hours,  they 


FIG.  149.— Foreign  body  lodged  on  conjunctiva  of  upper  lid.    Lid  everted  to 
show  the  usual  point  of  lodgement. 

become  imbedded  in  the  swelling  caused  by  their  pres- 
ence, and  even  large  masses  may  remain  concealed  for 
months.  The  heads  of  grass,  and  grain,  and  hairs  of 
caterpillars  are  likely  to  become  imbedded  in  the  swell- 
ing of  granulations  they  cause,  and  thus  remain  unde- 
tected. (See  Ophthalmia  Nodosa,  page  243.) 

Foreign  bodies  are  to  be  searched  for ;  first  by  careful 
inspection  of  the  exposed  portion  of  the  ocular  conjunc- 
tiva ;  then  by  the  eversion  of  the  upper  lid  (see  page  58); 
then  by  retraction  of  the  lower  lid  with  the  eyeball  turned 
strongly  upward  ;  and  then  the  lifting  of  the  upper  lid 
from  the  globe,  while  it  is  turned  strongly  downward. 
Points  of  inflammation  and  swelling  of  the  membrane 
are  to  be  very  carefully  exposed.  When  found  the  for- 
eign body  is  to  be  promptly  removed.  Usually  it  can  be 
wiped  away  with  a  pledget  of  cotton,  otherwise  it  may 
be  seized  by  fine  forceps.  Particles  of  quicklime,  or 
of  metal  that  has  entered  in  a  molten  state,  may  require 
snipping  loose  with  the  scissors. 

Foreign  bodies  in  the  cornea  cause  much  pain  and 
discomfort  when  they  project  sufficiently  to  scratch  the 
upper  lid  with  every  act  of  winking.  But  if  entirely 
imbedded,  they  may  be  unnoticed  until  after  one  or  more 
days'  attention  is  drawn  to  the  eye  on  account  of  the  re- 
sulting inflammation.  Then  there  are  found  pericorneal 
redness,  photophobia,  excessive  lacrimation,  a  contracted 
pupil,  and  often  reddening  of  the  optic  disk.  If  left 
alone,  suppuration  goes  on  around  the  foreign  body,  with 


494  FOREIGN  BODIES  IN  THE  CORNEA. 

all  the  dangers  of  a  suppurating  ulcer  of  the  cornea, 
until  the  foreign  body  is  loosened  and  wiped  away  by 
the  lids 

In  rare  cases,  suppuration  does  not  occur,  but  the  cor- 
neal  epithelium  proliferates  around  it  until  the  foreign 
body  is  imbedded  in  white  epithelial  masses,  which  lie  in  a 
depression  of  the  corneal  surface.  It  may  thus  be  retained 
for  weeks,  months,  or  even  years.  The  resulting  lesion  is  a 
white  or  gray  spot,  which  may  or  may  not  have  vessels 
running  to  it  from  the  limbus.  It  is  illustrated  in  Fig. 
150.  Particles  of  powdered  charcoal,  the  residue  of  a 
powder-grain,  and  a  few  other  aseptic  substances,  may 


FIG.  150.— Appearances  caused  by  foreign  body  retained  six  weeks  in  the 

cornea. 


remain  in  the  cornea  indefinitely  without  causing  irrita- 
tion. Other  substances  act  as  irritants  of  a  specific 
character,  as  the  fragments  of  oyster  shells,  which  cause 
"  oyster-shuckers'  keratitis." 

Diagnosis. — Haziness  of  the  cornea,  or  greater  con- 
gestion of  the  nearest  portion  of  the  pericorneal  zone, 
may  point  out  the  location  of  a  foreign  body  ;  or  this  may 
be  revealed  by  irregularity  of  the  corneal  surface,  which 
can  be  detected  by  placing  the  cornea  so  that  the  surgeon 
can  see  in  it  the  reflection  of  a  large  window,  and  wiping 
away  the  tears  and  mucus  with  a  swab  of  absorbent  cot- 
ton ;  or  by  a  drop  of  fluorescin  solution,  which  will  color 
any  point  where  the  corneal  epithelium  has  been  lost. 

But  a  foreign  body  may  be  deeply  imbedded,  and  may 
produce  the  most  serious  eifects,  although  so  small  as  to 
be  scarcely  visible  to  the  unaided  eye.  The  cornea  must 
therefore  be  searched  with  the  ophthalmoscope,  using 
the  strongest  convex  lens  with  which  it  is  furnished,  to 


MECHANICAL  INJURIES.  495 

discover  anything  lodged  in  front  of  the  pupil,  and  with  a 
good  magnifier  under  oblique  illumination. 

Foreign  bodies  in  the  cornea  must  be  distinguished 
from  small  opacities  in  the  deeper  media  (see  page  81), 
exudates  in  the  cornea,  or  even  specks  of  pigmentation  on 
the  iris. 

Treatment. — The  foreign  body  should  be  at  once  re- 
moved (see  Chapter  XIX)  with  the  damaged  and  soft- 
ened tissue  around  it.  This  includes  the  removal  of  the 
ring  of  brown  staining  which  quickly  forms  around  any 
foreign  body  containing  iron,  and  which  if  left  will 
separate  subsequently  after  prolonging  the  irritation. 
The  remaining  ulcer  is  to  be  treated  as  indicated  on 
pages  277  and  282. 

Foreign  bodies  in  the  sclera  may  be  quite  con- 
cealed by  the  swelling  of  the  conjunctiva.  If  left  there, 
they  may  remain  for  many  years  without  causing  irrita- 
tion, or  may  ultimately  be  thrown  off. 

Anterior  Chamber  and  Iris. — A  wound  through 
the  cornea  or  limbus,  with  the  diminished  ocular  tension, 
reveals  that  the  wounding  substance  has  penetrated  the 
globe.  Usually  it  goes  deeper,  but  sometimes  it  stops  in 
the  anterior  chamber  or  iris,  and  a  careful  search  should 
be  made  for  it  there.  Hemorrhage  into  the  anterior 
chamber  may  conceal  it  for  a  time  ;  but  usually  careful 
search  by  oblique  illumination  will  disclose  it,  for  the 
most  minute  foreign  bodies  have  not  sufficient  force  to 
pass  through  the  cornea. 

Treatment. — If  imbedded  in  the  iris,  the  foreign 
body  may  sometimes  be  picked  out  with  the  magnet  (if 
steel),  or  with  fine  forceps  introduced  through  an  incision 
in  the  nearest  part  of  the  periphery  of  the  cornea.  But 
usually  it  is  much  safer,  as  well  as  easier,  to  do  an  iri- 
dectomy,  removing  the  injured  portion  of  the  iris  with 
the  foreign  body  in  it.  When  the  foregn  body  lies  loose 
in  the  anterior  chamber,  it  should  be  extracted  through 
an  incision  in  the  lower  part  of  the  limbus.  The  subse- 
quent treatment  is,  cold  to  reduce  reaction,  rest,  the  use 
of  a  strong  mydriatic,  and  other  treatment  for  iritis.  All 


496  FOREIGN  BODY  IN  THE  IRIS. 

foreign  bodies  in  the  anterior  chamber  are  dangerous ; 
even  an  eyelash  or  bit  of  epithelium  carried  in  through 
a  perforating  wound  of  the  eornea,  beeomes  the  starting 
point  of  a  cyst  (see  page  332). 

I/ens. — In  the  lens  a  foreign  body  necessarily  causes 
cataract,  which  will  soon  conceal  it.  It  is  therefore  im- 
portant in  all  cases  of  foreign  body  iu  the  eye  to  carefully 
examine  the  lens  with  the  ophthalmoscope,  and  oblique 
illumination  and  a  good  magnifier,  as  soon  after  the 
injury  as  possible.  If  the  opacity  has  already  gone  so 
far  as  to  make  the  presence  of  the  foreign  body  uncertain, 
the  Rontgen  rays,  or  the  subsequent  presence  or  absence 
of  inflammation  of  the  uveal  tract,  must  be  relied  on  for 
a  diagnosis. 

A  foreign  body  in  the  lens  does  not  usually  cause  in- 
fection of  the  eye,  or  severe  inflammatory  symptoms, 
unless  there  is  great  swelling  and  rapid  disintegration  of 
the  lens.  With  the  foreign  body  in  the  lens  it  is  there- 
fore advisable  to  wait  until  the  traumatic  cataract  has 
matured,  or  so  far  advanced  as  to  make  its  removal 
necessary,  and  then  the  lens  should  be  extracted  through 
a  rather  large  incision,  with  an  upward  iridectomy,  if 
this  is  necessary  to  give  the  swollen  lens  free  exit.  The 
foreign  body  will  nearly  always  be  extruded  with  the  lens- 
substance  ;  if  it  is  not  it  must  be  removed  with  a  mag- 
net, scoop  or  forceps. 

Vitreous,  Retina,  and  Choroid. — A  foreign  body 
entering  the  vitreous  and  remaining  in  it,  or  penetrating 
the  coats  of  the  back  of  the  eye,  usually  causes  infection, 
and  loss  of  the  eye  through  purulent  or  chronic  plastic 
inflammation  ;  and,  so  long  as  it  remains,  it  constitutes 
an  especial  menace  to  the  other  eye,  through  sympathetic 
ophthalmitis.  The  foreign  body  may  be  small,  the  sight 
at  first  unimpaired,  less  pain  may  be  felt  than  from  a 
slight  abrasion  of  the  cornea,  and  yet  the  eye  may  be 
doomed  to  immediate  destruction. 

If  the  foreign  body  be  small  the  reaction  may  be  slight, 
severe  inflammation  not  setting  in  until  the  consequences 
of  infection  extend  from  the  wound  to  other  structures, 


MECHANICAL  INJURIES.  497 

but  the  ultimate  loss  of  the  eye  is  none  the  less  certain. 
If  the  foreign  body  be  large,  its  entrance  causes  so  much 
hemorrhage  and  general  disturbance  that  sight  is  at  once 
lost,  and  the  patient  may  show  decided  symptoms  of 
shock.  Great  edema  of  the  conjunctiva  and  lids  may 
quickly  occur,  so  that  in  a  few  hours  the  eye  shows  clear 
evidence  of  severe  injury,  and  before  these  symptoms 
subside  the  suppurative  or  chronic  plastic  inflammation 
is  fairly  started.  Some  foreign  bodies,  as  metallic  copper 
and  its  alloys,  cause  inflammation  by  their  chemical 
properties  even  when  aseptic. 

Diagnosis. — After  injury,  the  eye  should  be  thoroughly 
examined  at  the  earliest  possible  moment.  It  may  then 
be  easy  to  determine  the  presence  or  location  of  a 
foreign  body  which  a  few  hours  later  would  be  quite 
concealed  by  increased  opacity  of  the  lens  or  diffusion 
of  hemorrhage.  The  pupil  should  be  dilated  and  a  care- 
ful ophthalmoscopic  examination  made  of  every  part  of 
the  interior  of  the  eye.  Metallic  particles  are  generally 
detected  by  their  glitter.  Air-bubbles  in  the  vitreous 
which  appear  as  spheres  with  a  dark  outline,  although 
they  tend  to  rise  to  the  upper  part,  may  indicate  the 
direction  taken  by  the  foreign  body  ;  or  its  track  may  be 
marked  by  shreds  of  blood-clot.  A  localized  hemorrhage 
may  be  found  to  conceal  it;  or  a  wound  of  exit  may 
be  discovered. 

If  the  foreign  body  cannot  be  seen,  careful  inquiry 
must  be  made  as  to  the  probable  nature  of  the  body  by 
which  the  wound  was  inflicted,  its  size,  and  the  direction 
of  impact.  If  it  be  a  piece  broken  as  from  the  edge  of 
a  chisel,  the  size  and  shape  can  be  ascertained  by  in- 
spection of  the  tool.  If  a  fragment  is  believed  to  have 
struck  the  eye,  and  not  to  have  entered,  only  the  finding 
of  the  fragment  can  be  regarded  as  proving  this.  Patients 
are  likely  to  assert  positively  that  nothing  has  remained 
in  the  eye,  because  the  familiar  sensation  of  a  foreign 
body  on  the  surface  is  lacking,  or  because  they  hope  that 
the  injury  is  not  so  serious.  Sometimes  there  is  even  a 
clear,  but  incorrect,  history  of  the  wounding  body  having 

32 


498  FOREIGN  BODY  IN  THE   VITREOUS. 

dropped  out  after  injury.  If,  with  a  corneal  wound, 
there  is  also  penetration  of  the  iris  or  lens,  it  may  be  con- 
fidently assumed  that  the  wounding  body  has  passed  in ; 
and  we  may  presume  it  has  remained,  unless  it  be  some- 
thing like  a  piece  of  wire,  which  has  been  pulled  out 
afterward.  The  discovery  of  localized  hemorrhages  in 
the  fundus  quite  unconnected  with  the  wound  of  entrance 
is  a  strong  indication  of  the  presence  of  a  foreign  body. 

When  nothing  can  be  seen  with  the  ophthalmoscope, 
the  field  of  vision  should  be  taken  with  a  candle  in  the 
dark-room  ;  and  a  marked  scotoma,  or  other  defect  in  the 
visual  field  may  indicate  the  location  of  the  foreign  body. 
Instantaneous  blindness,  produced  by  a  small  foreign 
body,  as  a  bird-shot,  indicates  that  the  optic  nerve  has 
been  struck  either  at  the  disk  or  behind  the  eyeball. 
Ecchymosis  of  the  lids  appearing  some  time  after  the  in- 
jury, and  most  intense  near  the  margin  of  the  orbit,  or 
ecchymosis  of  the  conjunctiva,  appearing  similarly  in 
the  retrotarsal  fold,  is  evidence  of  orbital  hemorrhage, 
which,  if  not  from  the  wound  of  entrance,  proves  that 
the  foreign  body  has  not  lodged  in  the  eyeball,  but  has 
passed  on  into  the  orbit.  If  a  foreign  body,  as  a  bird- 
shot,  has  entered  the  eye  through  the  posterior  segment, 
the  softening  of  the  globe,  and  hemorrhage  in  the 
vitreous  announce  the  accident. 

The  Rontgen  rays  should  be  appealed  to  in  all  doubt- 
ful cases.  But  some  foreign  bodies  cast  no  appreciable 
shadow  from  them  ;  and  even  metallic  particles  if  smaller 
than  1  mm.  in  two  dimensions,  are  likely  to  give  no 
evidence  of  their  presence. 

Treatment  and  Prognosis. — The  earliest  possible  re- 
moval of  the  foreign  body  is  the  first  thing  to  be  consid- 
ered in  the  mass  of  cases.  It  should  usually  be  done  at 
any  cost,  even  to  the  removal  of  the  eye.  Particles  of 
iron  may  often  be  removed  by  the  magnet  (see  Chapter 
XIX).  The  certainty  of  the  removal  is  proportionate  to 
the  strength  of  the  magnet  and  the  size  of  the  bit  of 
steel.  Other  foreign  bodies,  not  influenced  by  the  magnet, 
must  be  removed,  if  possible,  by  forceps  or  a  scoop.  For 


MECHANICAL  INJURIES.  499 

this  purpose  it  is  the  surgeon's  duty  to  open  the  eyeball 
whenever  the  location  of  the  foreign  body  can  be  known 
with  strong  probability. 

The  second  point  is  to  remove  all  badly  damaged  and 
probably  infected  tissue.  On  this  account,  the  wound  of 
entrance  should  be  enlarged,  or  the  new  incision  made 
free  ;  and  all  tissue  in  which  the  foreign  body  is  entangled 
should  be  removed  with  it.  After  this,  the  treatment  is 
to  be  that  appropriate  to  wounds  of  the  parts,  careful 
cleansing,  cold  to  subdue  reaction,  rest  of  the  eye,  and 
rest  in  bed  until  reaction  begins  to  subside. 

A  few  foreign  bodies  pass  through  the  vitreous  into  the 
retina,  choroid,  or  sclera,  without  causing  infection  or  seri- 
ous inflammation.  These  have  usually  entered  through 
the  cornea,  and  iris,  or  lens,  or  have  passed  through 
the  lids.  They  are  usually  very  small.  When  such  a 
foreign  body  is  firmly  imbedded  and  has  remained  quite 
innocuous  for  several  days  or  weeks,  it  is  proper  to  let  it 
be  and  await  developments.  But  such  cases  are  so  rare, 
that  the  possibility  of  a  benign  course  ought  not  to 
influence  the  treatment  of  recent  cases. 

Even  after  the  successful  extraction  of  a  foreign  body 
the  safety  of  the  eye  is  not  assured.  In  the  majority  of 
cases,  useful  vision  will  be  lost,  and  the  injured  eye  may 
have  to  be  sacrificed  for  the  safety  of  the  other.  Even 
when  the  eye  seems  to  do  well  for  a  time,  it  may  become 
the  seat  of  a  slow  uveitis  that  after  weeks  or  months  will 
destroy  it.  The  prospect  of  a  useful  eye  is  best  after 
early  removal  of  a  small  foreign  body  which  has  entered 
through  the  iris  and  lens,  and  when  the  tissue  in  which 
it  lies  has  been  removed  with  it. 

BIBLIOGRAPHY. 

Injuries  of  the  Eyeball.     Wm.  Mackenzie,  "Practical  Treatise  on 

Diseases  of  the  Eye,"  Chap.  xii. 
Injuries  of  the  Eye  and  its  appendages.     A.  A.  Hubbell,  "American 

Text-book."" 
Rupture  of  the  Iris.     Geo.  C.  Harlan,  "  Trans.  Amer.  Ophthalmol. 

Soc.,"  1896. 
Contusion  of  the  Globe  with  Special  Reference  to  Commotio  Retinae. 

Max  Linde,  "  Ophthal.  Review,"  May,  1897. 


500  MECHANICAL  INJURIES. 

Removal  of  Powder  Grains  by  the  Galvano-Cautery.  Edward  Jack- 
son, "Ophthalmic  Review,"  Apr.,  1895. 

Foreign  Bodies  Retained  in  the  Cornea.  Edward  Jackson  "  British 
Medical  Journal,"  Jan.  8,  1898. 

Location  of  Pieces  of  Metal  by  the  Roentgen  Rays.  Wm.  M.  Sweet, 
"Archives  of  Ophthalmol.,  July,  1898  ;  Jas.  Mackenzie  David- 
son, "Brit.  Med.  Jour.,"  Jan.  "l,  1898;  S.  Snell  and  W.  Lang, 
"Trans.  Ophthal.,  Soc.  of  United  Kingdom,"  June,  1898. 

Quiescent  Foreign  Bodies  within  the  Eyeball.  W.  B.  Johnson, 
"  Trans.  Sect,  on  Ophthal.  Amer.  Med.  Assoc.,"  1893. 

Traumatic  Enophthalmos.  G.  E.  de  Schweinitz,  "  Trans.  Amer. 
Ophthalmol.  Soc.,"  1895. 

Orbital  Traumatism  Causing  Monocular  Blindness.  P.  A.  Callan, 
"  New  York  Eye  and  Ear  Infirmary  Rep.,"  1893. 

Removal  of  Steel  by  the  Electro  Magnet.  E.  E.  Holt,  "  Trans. 
Amer.  Ophthalmol.,  Soc.,"  1895. 

The  Electro-Magnet  of  Haab.  J.  E.  Weeks,  "  Trans.  Sect,  on  Oph- 
thalmol., Amer.  Med.  Assoc.,"  1899;  A.  Barkan,  "  Archives  of 
Ophthalmol.,"  Jan.  and  Mar.,  1898. 

Effects  of  Lightning  Stroke.  Rohmer,  "  Ophthalmic  Review,"  May, 
1895. 


CHAPTER  XVIII. 

KEMEDIES  AND  THEIR  APPLICATIONS. 
REST. 

Rest  of  the  eyes  may  be  made  absolute  by  the  use 
of  a  cycloplegic  and  the  complete  exclusion  of  light ;  or 
by  darkness  alone,  if  the  accommodation  has  been  lost  by 
age.  Commonly  only  relative  rest  is  required.  Under 
the  ordinary  bandage  light  reaches  the  retina  and  stimu- 
lates it  to  functional  activity.  Yet,  with  both  eyes  ban- 
daged there  is  very  little  incitement  to  exertion  of  the 
ocular  muscles,  and  under  cycloplegics  there  is  rest  from 
the  effort  of  accommodation. 

Suspension  of  the  customary  occupation  may  be  all  the 
rest  required  in  a  given  case.  Even  the  looking  at  dis- 
tant objects  is  a  valuable  rest  for  those  habitually  engaged 
at  close  looking.  Directions  to  rest  the  eyes  should 


REMEDIES  AND   THEIR  APPLICATIONS.         501 

specify  how  they  are  to  be  rested.     Rest,  by  use  of  lenses 
and  prisms,  is  discussed  in  Chapters  VII  and  VIII. 

Exclusion  of  the  light  is  indicated  in  active  inflam- 
mations of  the  retina  and  photophobias  of  retinal  origin. 
Absolute  exclusion  so  restricts  the  patient's  occupations, 
and  tends  so  toward  general  depression  of  feelings  and 
nutrition,  that  it  is  rarely  to  be  thought  of  except  for 
brief  periods,  even  though  in  some  ways  indicated.  A 
large  part  of  the  benefit  of  exclusion  of  light  is  to  be 
gained  by  carefully  avoiding  sharp  contrasts,  both  by 
preventing  sudden  changes  in  the  general  illumination, 
and  by  guarding  the  eye  from  receiving  at  one  time  on 
different  parts  of  the  retina  the  impressions  of  brightly 
and  feebly  illuminated  objects. 

General  rest,  through  its  powerful  influence  on  the 
circulation  and  the  nervous  system,  is  an  important  means 
of  combating  acute  inflammation.  Rest  in  bed  is  the 
most  complete  rest  for  those  who  find  it  not  irksome,  and 
it  includes  rest  from  many  stimuli  that  act  on  the  nervous 
system  when  the  patient  is  up.  It  is  most  important,  in 
the  early  stages  of  an  inflammation,  or  to  restore  an 
exhausted  patient  to  a  general  condition  favorable  to  heal- 
ing. When  it  becomes  decidedly  irksome,  it  is  generally 
no  longer  helpful,  but  may  have  an  effect  quite  the  oppo- 
site of  that  sought.  Even  when  the  object  of  so-called 
rest  is  simply  to  prevent  displacement  of  parts,  as  of  the 
flap  after  cataract  extraction,  or  a  graft  after  a  plastic 
operation,  it  may,  if  too  rigidly  enforced,  defeat  the  pur- 
pose, by  causing  a  nervous  irritability  in  which  the  patient 
will  not  be  able  to  avoid  the  slight  movements  that  are 
harmful. 

MASSAGE. 

Massage  of  the  eyelids,  often  combined  with  the 
use  of  boric  acid  powder  or  ointment,  is  sometimes  a 
valuable  aid  in  chronic  conjunctivitis  and  trachoma.  The 
required  movements  are  those  of  stroking  or  friction  of 
the  lid  upon  the  globe,  with  some  kneading  between  the 
forefingers  or  the  thumb  and  finger.  The  stroking  should 


502  MASSAGE. 

be  from  the  lid-margins.  The  manipulations  for  increas- 
ing the  efficiency  of  conjunct! val  applications  are  given 
on  page  505. 

For  episcleritis,  pannus,  and  glaucoma,  pressure  is  to  be 
made  upon  the  eyeball  through  the  closed  lids.  The 
direction  of  the  movements  should  be  radial,  from  over 
the  center  of  the  cornea  toward  the  equator  of  the  eyeball ; 
and  circular,  around  the  center  of  the  cornea  as  a  center. 

To  reduce  infiltrations,  lessen  the  effects  of  cicatricial 
contractions,  and  put  the  parts  in  the  best  condition  for 
plastic  operations,  pinching  up  of  the  skin  of  the  lids,  and 
kneading  or  rolling  it  between  the  thumb  and  finger,  is 
an  important  procedure. 

For  corneal  Opacities  massage  consists  in  stroking 
the  corneal  surface  in  a  radial  or  circular  direction  with 
the  back  of  a  lens-spoon,  spatula,  or  special  instrument 
made  for  the  purpose,  after  the  eye  has  been  brought 
under  the  influence  of  a  local  anesthetic.  Massage  of  the 
lens  is  considered  under  cataract  operations. 

Massage  for  glaucoma  is  performed  by  placing  the 
points  of  two  or  three  fingers  and  the  thumb  so  as  to 
press  through  the  lids  upon  the  anterior  portion  of  the 
sclera  ;  and  by  alternating  the  pressure  and  shifting  their 
position  causing  the  dimpling  of  the  different  parts  of  the 
eyeball. 

APPLICATIONS  OF  HEAT  AND  COLD. 

Dry  heat  is  applied  to  relieve  pain,  by  covering  the 
eye  with  hot  dry  cloths  and  changing  them  often  enough 
to  prevent  their  becoming  damp,  or  by  some  hot  object 
wrapped  in  flannel  and  applied  to  the  part.  A  nice  way 
is  by  the  Japanese  hot-box,  a  light  metal  box  in  which  is 
placed  a  piece  of  lighted  punk,  which  will  keep  it  hot 
enough  for  some  hours.  It  may  also  be  applied  by  a  coil 
of  rubber  tubing  through  which  hot  water  is  kept  con- 
stantly circulating  by  having  it  attached  at  both  ends  to 
a  small  boiler  kept  hot  by  a  small  alcohol  or  gas  lamp. 
Or  heat  may  be  applied  by  passing  hot  water  through 
the  Leiter  coil  of  small  lead  pipe. 


REMEDIES  AND  THEIR  APPLICATIONS.          503 

Hot  fomentations  are  used  to  relieve  pain,  secure 
resolution,  or  hasten  and  facilitate  suppuration.  They 
are  applied  by  placing  a  cloth  wrung  out  of  very  hot 
water  upon  the  eye,  and  changing  it  for  another  equally 
hot,  whenever  it  becomes  comfortably  cooled.  Generally 
they  are  continued  but  a  few  minutes  at  a  time,  such 
periods  being  repeated  if  needful  several  times  a  day. 
The  temperature  that  the  region  of  the  eye  will  endure 
with  ultimate  comfort  and  benefit  is  often  surprisingly 
high,  especially  when  it  has  had  a  few  minutes  to  become 
gradually  accustomed  to  the  heat. 

Hot  Water  as  a  Caustic. — In  some  cases  of  ulcera- 
tion  of  the  cornea,  an  excellent  influence  is  exerted  by 
dropping  upon  the  ulcer  one  or  two  drops  of  water  as 
near  the  boiling  temperature  as  possible.  To  do  this, 
the  eye  is  prepared  for  the  application.  Then  the  one  or 
two  drops  of  water  are  held  in  the  pipette  over  a  lamp- 
flame  until  just  at  the  boiling  point,  and  then  dropped  on 
the  ulcer  as  quickly  as  possible.  The  prolonged  use  of 
very  hot  applications  in  cancer  will  sometimes  destroy 
the  morbid  tissue.  A  sponge  wet  from  minute  to  minute 
with  boric  acid  solution,  as  hot  as  can  be  borne,  is  held 
to  the  part  twenty  minutes  of  every  two  or  three  hours. 

Hot  Water  as  a  Styptic. — The  best  agent  to  check 
bleeding  after  enucleation  of  the  eyeball,  or  removal  of  a 
tumor,  is  hot  water.  It  may  be  applied  by  wringing  it 
out  of  sponges  as  hot  as  can  be  borne,  so  as  to  fall  in  a 
stream  on  the  bleeding  area ;  or  it  may  be  better  applied 
from  a  large  pipette,  such  as  is  used  for  washing  the  con- 
junctiva. It  seems  to  exert  no  deleterious  influence  on 
the  conjunctiva  or  wound-surface,  even  when  so  hot  that 
the  neighboring  skin  must  be  carefully  guarded  from  the 
overflow,  for  fear  of  its  being  burnt  and  blistered. 

Poultices  must  be  used  with  caution  about  the  eye, 
since  they  may  aggravate  conjunctiva!  and  corneal  in- 
flammations, or  favor  disastrous  intra-ocular  suppuration. 
Sometimes  as  for  a  stye  or  other  lid-inflammation,  the 
suppurating  point  may  be  covered  by  a  poultice  so  ad- 


604  HEAT. 

justed  as  to  leave  free  a  large  part  of  the  lids  and  the 
fissure  between  them. 

Cold  is  used  upon  the  eye  to  prevent  or  lessen  the 
reaction  after  injury,  and  to  combat  acute  inflammation 
in  its  early  stages.  It  is  contraindicated  when  there  is 
risk  of  sloughing  of  the  cornea,  or  when  its  application 
causes  serious  discomfort.  To  do  good  the  application  of 
cold  must  be  continuous.  A  common  method  is  to  place 
by  the  patient's  head  a  block  of  ice  upon  which  are  laid 
three  or  four  pieces  of  surgical  lint,  or  small  cloths.  One 
of  these  is  laid  upon  the  closed  lids  for  a  minute  or  two, 
until  it  becomes  a  little  warm,  when  it  is  replaced  by 
another  piece  and  laid  back  on  the  ice  to  cool  again. 
Cold  may  also  be  applied  by  pounded  ice  in  a  small, 
light,  rubber  bag,  or  by  ice-water  run  through  a  coil  of 
lead  or  rubber  tubing. 

THE  MAKING  OF  APPLICATIONS  TO  THE  CONJUNCTIVA. 

Conjtmctival  Instillations. — Solutions  are  dropped 
in  the  conjunctival  sac,  either  that  they  may  be  absorbed 
through  the  cornea  and  thus  reach  and  influence  the 
interior  of  the  eye,  or  for  their  direct  action  on  the  con- 
junctiva itself. 

To  affect  the  interior  of  the  eye  it  is  important  that 
the  solution  should  reach  the  cornea  undiluted.  The 
best  effect  is  obtained  by  having  the  patient  look  down- 
ward, fixing  the  gaze  on  some  point  on  the  floor  and  star- 
ing fixedly  at  it  with  the  other  eye.  The  upper  lid  of 
the  eye  in  which  the  solution  is  to  be  placed  is  then 
gently  raised  by  slight  traction  on  the  skin  of  the  lid 
with  one  finger  of  the  left  hand,  and  retained  thus  by 
pressure  of  the  skin  against  the  upper  margin  of  the 
orbit.  If  the  patient's  head  rests  against  a  firm  support 
where  he  cannot  draw  back  from  this  pressure,  it  is  easy 
thus  to  control  the  movements  of  the  lid.  The  patient's 
head  should  be  tilted  back  so  far  that  when  the  upper  lid 
is  drawn  up  the  lashes  will  be  out  of  the  way. 

With  the  ordinary  rubber-bulb    pipette  or  medicine 


REMEDIES  AND  THEIR  APPLICATIONS.         505 

dropper,  the  required  drop  or  drops  are  then  deposited 
on  the  upper  margin  of  the  cornea.  They  should  not 
be  allowed  to  fall  any  considerable  distance,  on  account 
of  the  increased  shock  from  the  force  with  which  they 
will  strike  the  eye.  On  the  other  hand,  the  dropper 
should  not  touch  the  patient  for  fear  of  infection.  An 
instillation  will  be  more  agreeable  if  the  solution  is 
brought  to  blood  heat,  or  a  little  warmer,  before  applying 
it.  After  the  application,  the  lid  is  to  be  held  open  until 
the  patient  so  far  regains  control  over  his  eyes  that  he 
can  again  hold  them  open  without  assistance. 

To  Affect  the  Conjunctiva. — If  the  drops  are  intended 
not  for  corneal  absortion  but  to  influence  the  conjunctiva, 
the  patient  may  be  allowed  to  roll  the  eyes  up,  the  lower  lid 
being  drawn  down  by  the  finger  pressed  against  the  mar- 
gin of  the  orbit,  forming  a  cup  in  which  drops  may  be 
placed.  Such  an  application  can  be  made  most  effectively 
when  the  patient  is  lying  down.  The  lower  lid  being 
still  drawn  from  the  globe,  the  eye  should  be  rolled  in 
various  directions  until  the  solution  is  diffused  through- 
out the  conjunctival  sac.  As  soon  as  the  lids  are  allowed 
to  close  tightly,  much  of  the  solution  will  be  expelled. 

When  it  is  desired  to  prevent  fluids  placed  in  the  con- 
junctiva from  passing  with  the  tears  into  the  nose,  as  to 
prevent  the  constitutional  effects  of  a  mydriatic  through 
its  absorption  from  the  mucous  membrane  of  the  nose 
and  throat,  gentle  traction  should  be  made  on  the  lids 
near  the  inner  canthus,  in  such  a  way  as  to  turn  the 
puncta  away  from  the  eye,  and  a  pledget  of  absorbent 
cotton  held  in  contact  with  the  puncta.  Simple  pressure 
upon  the  canaliculi,  through  often  recommended,  unless 
so  strong  as  to  be  very  unpleasant,  is  probably  of  little 
avail  for  this  purpose. 

The  eye-douche  may  also  be  used  to  make  applica- 
tions to  the  conjunctival  sac.  The  solution  is  placed  in 
it,  and  the  eye  applied  to  it  and  opened.  On  throwing  the 
head  back  the  solution  enters  the  conjunctival  sac. 

Washing  Out  the  Conjunctiva. — The  water  or 
solution  used  should  be  at  blood-heat  or  warmer.  The 


506  WASHING  THE  CONJUNCTIVA. 

patient's  head  should  be  thrown  far  back.  The  patient 
or  an  assistant  should  hold  a  mass  of  absorbent  cotton  to 
the  cheek  so  as  to  catch  the  overflow  of  fluid.  The 
pipette  should  have  rather  a  large  opening,  and  a  bulb 
holding  one  or  two  fluid  ounces.  The  upper  lid  should 
be  drawn  away  from  the  eyeball  by  the  lashes,  and  the 
solution  driven  into  the  conjunctiva!  sac  with  something  of 
a  spurt.  This  is  repeated  with  the  stream  directed  toward 
the  middle  and  each  end  of  the  upper  lid,  along  the  lower 
lid,  and  into  the  canthus.  The  escaping  fluid  is  then  to 
be  wiped  away,  and  the  process  repeated  as  often  as 
necessary. 

Applications  of  Astringent  and  Caustic  Solu- 
tions.— When  the  solution  to  be  applied  to  the  conjunc- 
tiva is  so  irritant  that  it  would  be  unsafe  to  freely  instil 
it,  it  is  applied  by  means  of  a  mop  made  by  twisting  a 
little  absorbent  cotton  around  the  end  of  a  tooth-pick,  or 
match-stick.  This  is  dipped  into  the  solution,  and  any 
excess  is  pressed  out  against  the  side  of  the  bottle.  The 
lid  is  everted,  as  for  examination  (see  page  57).  The 
eye  is  turned  strongly  down  while  the  application  is  made 
to  the  upper  lid,  and  up  for  the  lower  lid.  The  applica- 
tion having  been  thus  made  to  the  exposed  portion  of  the 
lid-surface,  the  lid  is  to  be  turned  in,  and  with  the  eye 
still  turned  downward,  the  upper  lid  is  pushed  back  as 
far  as  possible  under  the  brow  ;  and  a  similar  manipula- 
tion practiced  for  the  lower  lid.  This  makes  the  part  of 
the  lid  reached  by  the  mop  a  carrier  of  the  remedy  into 
the  retrotarsal  fold  which  cannot  be  so  reached.  The 
strength  of  an  application  can  be  regulated  largely  by  the 
dryness  or  saturation  of  the  mop. 

Solid  applications  to  the  conjunctiva  are  made 
after  similar  exposure  of  the  membrane  by  eversion  of 
the  lids.  The  surface  applied  to  the  conjunctiva  must 
be  smooth,  and  not  applied  with  unnecessary  force.  To 
get  a  strong  effect,  the  application  must  be  made  slowly 
to  give  the  solid  time  to  dissolve.  Where  a  slight  effect 
is  sought,  the  surface  may  be  dried  or  partly  dried  and 
tquched  lightly. 


REMEDIES  AND  THEIR  APPLICATIONS.         507 

Medicated  gelatin  disks  are  applied  by  dipping 
in  water  to  soften  their  edges,  and  then  with  a  camel's- 
hair  brush  laying  the  disk  on  the  scleral  conjunctiva  near 
the  upper  outer  margin  of  the  cornea.  The  eye  is  then 
to  be  closed  for  several  minutes. 

Applications  to  the  conjunctiva  in  children, 
who  are  liable  to  resist,  or  by  a  sudden  movement  of  the 
head  to  endanger  the  eye,  should  be  made  thus :  The 
child  is  seated  on  the  lap  of  the  assistant  or  parent  with 
its  back  to  the  surgeon,  who  spreads  a  towel  or  oil-cloth 
apron  upon  his  knees,  and  then  takes  the  child's  head 
between  them.  The  assistant  controls  the  child's  hands 
and  legs ;  and  the  surgeon  can  hold  the  head  perfectly 
secure  and  steady  between  his  knees,  while  having  both 
hands  free  for  use  in  making  the  application. 

Subconjunctival  injections  are  made  with  the 
hypodermic  syringe,  through  a  fine  needle.  After  the  use 
of  a  local  anesthetic,  the  conjunctiva  is  seized  with  fixa- 
tion-forceps, just  back  from  the  corneal  margin.  The 
point  of  the  needle  is  thrust  fairly  into  the  loose  subcon- 
juuctival  tissue,  and  the  required  number  of  drops, 
usually  2  to  6,  gently  expelled.  The  patient's  head 
should  be  firmly  supported.  Some  of  the  solutions  used 
cause  severe  pain.  The  needle  is  quickly  withdrawn,  and 
the  lid  pressed  for  a  minute  or  so  against  the  point  of 
puncture  to  retain  the  fluid,  and  diffuse  it  throughout  the 
adjoining  loose  tissue. 

ANTISEPTIC  AND   CLEANSING  SOLUTIONS. 

Heat,  the  most  generally  reliable  of  antiseptic  agencies, 
may  be  applied  to  solutions  liable  to  be  contaminated,  by 
repeatedly  bringing  them  to  the  boiling-point,  or  by  boil- 
ing for  five  minutes  whenever  used  in  the  eye. 

Water  is  the  most  important  ingredient  of  all  antisep- 
tic solutions.  The  thorough  washing  away  of  infectious 
materials,  and  of  what  may  serve  as  a  nidus  for  patho- 
genic bacteria,  is  far  more  important  than  the  chemical 
action  of  any  solution  that  can  be  safely  used  in  the  con- 
junctival  sac ;  for  it  is  of  prime  importance  that  such 


508  ANTISEPTICS. 

solutions,  which  must  be  used  freely  to  be  effective,  shall 
not  be  in  any  way  injurious. 

Hydrogen  dioxid  (peroxid  of  hydrogen]  as  fur- 
nished in  3  per  cent,  solution  (Aqua  Hydrogenii  Dioxidi, 
U.  S.  P.)  is  the  best  agent  to  cleanse  freely  opened  abscess- 
cavities  or  sinuses,  the  liberation  of  oxygen  wherever  it 
comes  in  contact  with  pus  forcing  out  the  contents  of 
small  pockets  and  folds.  It  is  also  a  powerful  styptic ; 
and  on  this  account,  it  must  not  be  used  when  it  is 
desired  to  favor  bleeding. 

Hydrogen  dioxid,  1.  (f  3Jj) ; 

Water,  4.  (f  Ij)  ; 

may  be  used  in  purulent  conjunctivitis. 

Formaldehyd  in  saturated  40  per  cent,  solution  in 
water,  called  formalin,  is  a  powerful  antiseptic,  but  very 
irritant.  Dilutions  from  1  :  20  to  1  :  200  may  be  used  to 
cauterize,  corneal  ulcers.  Solutions  of  1  :  500  to  1  :  2000 
are  effective  in  cleaning  abscess-cavities  and  sinuses,  and 
for  disinfecting  the  skin  of  the  lids  and  the  eyelashes 
prior  to  operation. 

Formalin,  1.  (Tuj) ; 

Distilled  Water,  2000.  (ffnr)  ; 

may  be  used  to  cleanse  the  conjunctiva  in  purulent  con- 
junctivitis, although  even  this  causes  considerable  smart- 
ing. A  solution  of  1  : 4000  is  preferable  for  cleansing 
the  conjunctiva  prior  to  operation.  Formaldehyd  is  the 
best  chemical  disinfectant  for  surgical  instruments.  (See 
Chapter  XIX.) 

Ttikresol  is  one  of  the  least  irritating  of  reliable  ger- 
micides. The  following  solution  may  be  made  the  men- 
struum for  collyria,  and  will  prevent  their  contamination 
by  bacterial  growths : 

Trikresol,  1.  (itlj)  5 

Distilled  water,  1000.  (f  gij). 

Or  a  solution  of  double  that  strength  may  be  used  to 
rinse  the  pipettes  and  to  keep  them  in. 


REMEDIES  AND  THEIR  APPLICATIONS.         509 

Mercuric  chloric!  (bichlorid  of  mercury,  corrosive 
sublimate)  may  be  used  in  washing  out  abscess-cavities 
and  sinuses,  and  for  cleansing  the  skin  of  the  lids.  The 
proper  strength  is 

Mercuric  chlorid  (corrosive),  1.  (gr.  j)  ; 

Distilled  water,  1000.  (f  3ij). 

For  use  as  a  wash  in  the  conjunctiva  it  should  have  a 
strength  of  not  over  1  :  5000,  and  is  best  replaced  by  less 
irritant  solutions.  In  the  strength  of  1  :  500  it  is  applied 
to  the  inner  surface  of  the  lids  for  trachoma. 

Mercuric  iodid  (biniodid  of  mercury)  is  used  as  an 
antiseptic  wash,  in  what  is  called  Punas'  solution : 

Mercuric  iodid,  1.  (gr.  |)  ; 

Absolute  alcohol,  400.  (f  3J) ; 

Distilled  water,          to  make  20,000.  (f  gvi). 

Mercuric  cyanid  is  similarly  employed  in  the 
strength 

Mercuric  cyanid,  1.  (gr.  j) ; 

Distilled  water,  5000.  (f  gx). 

CONJUNCTIVAL  APPLICATIONS. 

Silver  nitrate  is  used  in  the  Crede  method  for  des- 
troying the  virus  of  ophthalmia  neonatorum,  by  dropping 
into  the  eyes  of  the  new-born  child  a  few  drops  of  the 
following  solution 

Silver  nitrate,  2.  (gr.  x) ; 

Distilled  water,  100.  (f  3j). 

A  solution  of  the  same  strength,  or  two  or  three  times 
this  strength,  is  applied  to  the  lids  once  every  one  or  two 
days  in  purulent  ophthalmia,  during  the  period  of  profuse 
purulent  discharge.  After  the  application  of  one  of  these 
solutions  the  excess  is  often  neutralized  by  a  solution  of 
sodium  chlorid.  But  it  is  better  to  have  no  excess.  The 
severity  of  the  application  is  readily  modified  and  con- 


510  CONJUNCT!  VAL  APPLICATIONS. 

trolled  by  the  saturation  of  the  cotton  applicator.  Numer- 
ous solutions  of  slightly  different  strengths  are  therefore 
unnecessary.  One  solution,  weaker  than  the  above,  is 
useful  for  catarrhal  conjunctivitis,  as  the  following  : 

Silver  nitrate,  1.  (gr.  ij); 

Distilled  water,  250.  (f  §j). 

Organic  salts  of  silver,  recently  introduced  as  sub- 
stitutes for  the  nitrate,  are  less  irritant  ;  but  their  thera- 
peutic value  is  not  yet  so  well  established.  The  principal 
one  is  protargol  a  combination  of  silver  with  a  proteid 
base.  It  is  stable  and  freely  soluble. 

Protargol,  1.  (gr.  x)  ; 

Distilled  water,  50.  (f  Jij)  ; 

may  be  used  as  a  collyrium  in  conjunctivitis,  or  to 
cleanse  the  lacrimal  sac  in  dacryocystitis.  A  20  per  cent. 
solution  is  used  as  an  application  to  the  everted  lids  in 
purulent  conjunctivitis. 

Potassium  permanganate  is  used  in  disinfecting 
the  skin  or  conjunctival  sac,  and  as  a  cleansing  wash  in 
purulent  conjunctivitis. 

Potassium  permanganate,  1.  (gr.  j)  ; 

Distilled  water,  2000.  (f  3iv). 

Pyoktanin  is  a  name  applied  to  both  the  aniline  dyes 
methyl  violet  (blue  pyoktanin)  and  aura  m  in  (yellow 
pyoktanin).  They  are  chiefly  useful  in  chronic  inflam- 
mation of  the  lacrimal  passages.  The  following  may  be 
used  as  a  collyrium  or  to  cleanse  the  passages  : 

Methyl  violet,  1.  (gr.  j)  ; 

Distilled  water,  1000. 


Boric  acid  solution  is  used  slightly  weaker  than  a 
saturated  solution. 

Boric  acid,  1.  (gr.  xij); 

Distilled  water,  40.  (f  gj). 

It  must  be  made  sterile  by  boiling.     When  prescribed  as 


REMEDIES  AND  THEIR  APPLICATIONS.         511 

a  collyrium,  rose-water  or  camphor-water  may  be  used. 
It  is  often  prescribed  in  combination  with  borax,  thus : 

Sodium  biborate,  1.  (gr.  vj) ; 

Boric  acid,  2.  (gr.  xij) ; 

Rose-water,  80.  (f  Ij). 

Sodium  chlorid  solution  is  used  to  cleanse  the  eye, 
wash  out  the  anterior  chamber,  and  to  float  epithelial 
grafts  for  plastic  operations.  It  is 

Common  salt,  1.  (gr.  iij) ; 

Distilled  water,  160.  (f  3j). 

DUSTING  POWDERS. 

lodoform,  for  use  in  the  eye,  should  be  in  impalpable 
powder.  It  is  dusted  in  as  a  dressing  for  wounds  or 
after  operations. 

Boric  acid,  aristol,  and  acetanilid  may  be  simi- 
larly used.  They  are  free  from  the  disagreeable  odor  of 
iodoform,  but  it  is  not  certain  that  either  is  as  beneficial 
as  iodoform. 

CAUSTICS,   ASTRINGENTS,  AND  IRRITANTS. 

Arsenic,  for  the  destruction  of  malignant  growths, 
may  be  used : 

Arsenous  acid,  1.  (gr.  j)  ; 

Creasote,  60.(f3J). 

This  must  not  be  used  on  a  large  surface.  It  requires 
three  or  four  days  to  do  its  work,  and  is  quite  painful ;  it 
is  to  be  followed  by  poulticing  until  the  slough  separates. 

25inc  chlorid  is  used  for  the  same  purpose  as  the 
above. 

Zinc  chlorid  and  wheat  flour,  equal  parts,  are  mixed 
with  a  little  water  to  form  a  thick  paste.  It  may  be 
spread  on  the  walls  of  the  orbit,  when  all  oozing  has 
stopped,  after  removal  of  the  orbital  contents  for  a  malig- 
nant growth. 

Copper   sulphate   is   used  in  crystal.     The  crystal 


512  CAUSTICS  AND  ASTRINGENTS. 

may  be  cut  or  ground  into  the  more  convenient  form  of  a 
pencil.  It  should  be  rinsed  and  wiped  off  after  using, 
and  care  taken  to  see  that  it  always  presents  a  smooth 
surface.  If  allowed  to  remain  damp,  it  quickly  roughens. 

l/apus  divinus  is  composed  of  copper  sulphate,  potas- 
sium nitrate,  and  alum,  each  equal  parts,  fused  together 
with  2  per  cent,  of  their,  united  weight  of  camphor. 

Mitigated  silver  nitrate  stick  is  made  by  fusing 

Silver  nitrate,  1  part. 

Potassium  nitrate,  2  parts. 

Alum  crystal,  preferably  reduced  to  the  more  conve- 
nient form  of  a  stick,  is  an  efficient  astringent,  to  be  ap- 
plied to  the  everted  lids  for  chronic  conjunctivitis.  It  is 
much  less  irritant  than  the  substances  mentioned  above. 

Solutions  of 

Alum,  1.  (gr.  xx)  ; 

Distilled  water,  25. 


are   also   useful   in   the  same  cases  of  chronic   conjunc- 
tivitis. 

Tannin  dissolved  in  glycerin  is  a  most  valuable  local 
application  for  phylctenular  conjunctivitis,  and  the  late 
stages  of  trachoma. 

Tannin,  1.  (sj)  ; 

Glycerin,  8.  (f  |j), 

is  the  proportion  commonly  used.  Half  this  strength 
will  sometimes  be  equally  effective  ;  and  the  official  gly- 
cerite  (U.  S.  P.)  of  twice  the  strength  may  be  employed. 
£inc  sulphate,  the  active  ingredient  of  many  popu- 
lar collyria,  has  been  found  especially  valuable  in  diplo- 
coccus  conjunctivitis.  It  may  be  used  in 

Zinc  sulphate,  1.  (gr.  j)  ; 

Distilled  water,  200. 


Two  or  three  drops  may  be  instilled  once  or  twice  a  day. 
Solutions  either  stronger  or  weaker  than  this  may  be 
employed. 


REMEDIES  AND   THEIR  APPLICATIONS.         513 

2Jinc  chlorid  is  recommended  by  Gifford  for  diplo- 
coccus  conjunctivitis  in  the  strength 

Zinc  chlorid,  1.  (gr.  j)  ; 

Distilled  water,  500.  (f  3j) ; 

to  be  used  like  the  zinc  sulphate  solution. 

Boroglycerid  (glyeeritum,  boroglycerini,  U.  S.  P.)  is 
used  in  trachoma  and  chronic  catarrhal  conjunctivitis, 
usually  of  full  strength,  but  it  may  be  diluted  with  an 
equal  quantity  of  glycerin. 

lodin  dissolved  in  glycerin  or  petrolatum  is  to  be  ap- 
plied on  cotton  to  the  everted  lids  for  trachoma. 

lodin,  1.  (gr.  vj)  ; 

Glycerin,  75.  (f  sj). 

Jequirity,  the  bean  of  the  abrus  precatorius,  is  used 
to  excite  acute  inflammation  in  trachoma,  either  by  dust- 
ing on  the  everted  lids  an  extremely  fine  powder,  or  by 
painting  them  with  a  2  per  cent,  infusion. 

OINTMENTS. 

Yellow  oxid  of  mercury  is  an  impalpable  powder 
prepared  by  precipitation.  Chemically,  it  is  mercuric 
oxid,  the  same  as  the  red  oxid,  which  is  unsuitable  for 
application  within  the  eye  because  of  its  crystalline  char- 
acter. The  official  ointment  (U.  S.  P.)  is  too  strong  (10 
per  cent.),  but  may  be  used  properly  diluted. 

Yellow  oxid  of  mercury,  1.  (gr.j); 

Petrolatum  (soft),  60.  (§)  ; 

is  a  good  strength  to  begin  with.  But  it  may  do  best  if 
only  half  this  strength,  or  of  considerably  greater 
strength.  The  preparation  is  liable  to  alter  by  prolonged 
exposure  to  light. 

Boric  acid  ointment  is  of  value,  with  massage  of 
the  lids,  for  trachoma.  It  may  be  made : 

Boric  acid,  1.  (gr.  vj) ; 

Lanolin  (Adeps  Lanse  Hydrosus, 

U.  S.  P.)  10.  (3  j). 

33 


514  OINTMENTS. 

lodoform  ointment  may  be  used  instead  of  the 
powder : 

Precipitated  iodoform,  1.  (gr.  vj); 

Petrolatum,  soft,  10.  (3j). 

2£inc  ointment  is  an  excellent  protective;  but  for 
use  about  the  lids  the  official  ointment  (U.  S.  P.)  of  1  to 
5  may  with  advantage  be  diluted  with  once  or  twice  its 
weight  of  lanolin. 

ANESTHETICS. 

General  anesthesia  is  now  required  in  ophthalmic 
surgery  mainly  for  enucleation  of  the  eyeball,  removal  of 
orbital  tumors,  for  important  operations  on  inflamed  eyes, 
as  iridectomy  for  glaucoma,  or  extraction  of  traumatic 
cataract,  and  for  extensive  use  of  the  cautery  as  in 
destroying  powder  grains.  Ether  should  usually  be  em- 
ployed as  the  safer  anesthetic,  except  for  the  use  of  the 
cautery  when  chloroform  must  be  given. 

l/ocal  anesthesia  sufficient  for  most  operations  on 
the  eye  is  produced  by  the  instillation  of  cocain  or  holo- 
cain.  For  foreign  bodies  in  the  cornea,  pterygium  and 
similar  operations  involving  only  superficial  structures, 
the  anesthesia  thus  produced  is  perfect.  For  operations 
on  the  ocular  muscles  only  the  pull  on  the  tendon  is 
necessarily  painful.  Chalazion  operations,  and  others  in- 
volving the  lids,  are  not  rendered  painless  by  such  instil- 
lations. Cataract  operations,  and  iridectomies  on  eyes 
free  from  inflammation,  usually  cause  little  discomfort. 
For  these  latter  operations  cocain  should  be  first  instilled 
about  fifteen  minutes  before  commencing  the  operation, 
and  the  application  repeated  once  or  twice  at  intervals  of 
five  minutes.  For  more  superficial  operations  the  time 
after  the  first  instillation  need  not  be  more  than  five 
minutes ;  operation  should  be  completed  in  about  twenty 
minutes  after  the  last  application,  since  by  that  time 
anesthesia  is  diminished.  Cocain  causes  drying  of  the 
cornea  and  softening  of  the  eyeball.  Holocain  is  free 
from  the  above  disadvantages,  and  it  produces  anesthesia 


REMEDIES  AND   THEIR  APPLICATIONS.         515 

more  quickly,  but  its  influence  is  more  brief.  Cocain 
constricts  the  vessels  and  lessens  hemorrhage,  holocain 
does  not. 

Cocain  may  be  used  in  solutions  of  from  2  to  10  per 
cent.,  the  stronger  for  operations  on  the  lids,  or  upon 
inflamed  eyes,  on  which  it  produces  comparatively  little 
effect.  A  good  solution  for  general  use  is 

Cocain  hydrochlorate,  5.  (gr.  iij)  ; 

Distilled  \\;ater,  100.  (f  3J). 

It  should  be  fresh  or  freshly  sterilized  with  heat. 
Holocain  is  used  in 

Holocain,  1.  (gr.j); 

Distilled  water,  100.  (fll-  100). 

It  is  decidedly  antiseptic,  such  a  solution  inhibiting 
and  destroying  the  pus-organisms  coming  in  contact  with 
it. 

Uucain  is  a  local  anesthetic  which  causes  too  much 
irritation  when  applied  to  the  conjunctiva,  to  be  gen- 
erally used  in  ophthalmic  surgery. 

Infiltration  anesthesia,  as  worked  out  by  Schleich, 
depends  upon  injecting  into  and  afterward  under  the  skin 
a  weak  saline  solution  containing  a  little  cocain.  Weaker 
and  stronger  solutions  are  used,  but  the  following  is 
recommended  : 


Common  salt,  1.  (gr.  j)  ; 

Cocain  hydrochlorate,  1.  (gr.  j)  ; 

Distilled  water,  500.  (f  3j). 


A  drop  or  two  of  this  is  injected  into  the  skin,  causing 
a  small  weal.  The  needle  is  then  withdrawn  and  rein- 
troduced  in  the  edge  of  this  weal,  which  is  already  anes- 
thetic, and  a  drop  or  two  more  injected  extending  the  area 
of  anesthesia,  and  this  is  repeated  until  a  sufficient  area  is 
obtained.  For  deeper  anesthesia  the  needle  is  thrust 
through  the  anesthetic  area  thus  obtained,  and  the  deeper 
tissues  injected.  The  thin  skin  of  the  lids,  and  their 
great  vascularity  are  not  particularly  favorable  for  this 


516  ANESTHETICS. 

method.     The  injections  must  be  made  rather  quickly  to 
secure  the  best  anesthesia. 

MYDRIATICS. 

Cocain  hydrochlorate  is  the  best  mydriatic  for  pro- 
ducing brief  dilatation  of  the  pupil  in  the  dark  room. 
It  gives  wide  dilatation  in  the  dark  room  while  not 
destroying  the  reaction  to  light,  or  materially  lessening 
the  power  of  accommodation  ;  so  that  it  causes  the  patient 
little  annoyance.  It  produces  wider  dilatation  of  the 
senile  pupil  than  the  other  mydriatics,  and  with  much  less 
risk  of  causing  glaucoma.  A  drop  of  the  ordinary  anes- 
thetic solution  may  be  used  from  40  to  50  minutes  before 
it  is  required  to  have  the  pupil  dilated.  Its  influence 
passes  off  in  twelve  hours. 

Euphthalmiii  hydrochlorate  in  5  per  cent,  solution 
dilates  the  pupil  almost  as  much  as  cocain,  and  produces 
rather  more  weakening  of  the  accommodation.  The  dila- 
tation it  causes  is  maintained  in  strong  sunlight,  and  re- 
covery from  its  effects  requires  about  twenty-four  hours. 
It  is  the  best  brief  dilator  of  the  pupil  for  examination 
in  a  strong  light. 

Homatropin  makes  a  good  dilator  of  the  pupil ;  the 
effect  of  which  passes  off  in  about  one  day  if  used  in  the 
following  solution  : 

Homatropin  hydrobromate,  1.  (gr.  j)  ; 

Distilled  water,  500.  (f  gj). 

Cocain  and  homatropin  make  a  most  satisfactory 
mydriatic  in  this  combination  : 

Cocain  hydrochlorate,  4.  (gr.  j) ; 

Homat.  hydrobromate,  1.  (gr. 

Distilled  water,  1000.  (f  si 

Atropin  is  better  where  it  is  desired  to  keep  the  pupil 
continuously  dilated,  as  for  nuclear  cataract. 

Atropin  sulphate,  1.  (gr.    ) ; 

Distilled  water,  2000. 


REMEDIES  AND  THEIR  APPLICATIONS,         517 

A  single  drop  instilled   once   every  two  or   three  days 
will  answer  the  purpose.     (See  also  Oydoplegics.) 

CYCLOPLEQICS. 

Hotnatropin  is  the  best  cycloplegic  for  diagnostic 
purposes.     The  solution  used  is  : 

Homatropin  hydrobromate,  1.  (gr.  iij)  ; 

Distilled  water,  40. 


A  drop  of  this  solution  is  instilled  in  the  eye  every  five 
minutes  until  four  to  six  have  been  thus  applied.  The 
maximum  effect  is  produced  in  one  hour.  Recovery 
begins  an  hour  or  two  later,  and  is  usually  complete  in 
forty-eight  hours.  The  instillations  should  be  carefully 
made  by  the  surgeon,  or  a  trained  assistant.  So  used, 
homatropin  is  a  reliable  cycloplegic  not  likely  to  cause 
constitutional  symptoms. 

Atropin  sulphate  exerts  the  most  prolonged  control 
over  the  ciliary  muscle.  It  is  therefore  fitted  for  use 
when  the  accommodation  is  to  be  kept  continuously  in 
abeyance,  and  the  eye  given  a  period  of  mydriatic  rest. 
It  is  especially  indicated  when  the  instillations  are  to  be 
made  by  unskilled  persons,  who  may  fail  to  make  some  of 
them  effective.  The  strength  used  for  this  purpose  is  : 

Atropin,  1.  (gr.  iv);    * 

Distilled  water,  120.  (f  gj). 

One  drop  of  this  is  instilled  three  times  a  day. 

Duboisin,  hyoscyamin,  and  scopolamin  salts  are 
used  for  practically  the  same  purposes  as  atropin.  They 
resemble  each  other  very  closely  in  their  action,  and  have 
the  special  advantage  over  atropin  of  a  shorter  period  of 
recovery.  Weight  for  weight  they  have  more  than  twice 
the  physiological  effect  of  atropin.  The  usual  solutions 
are: 

Hyoscyamin  hydrobromate,  1.  (gr.  j)  ; 

Distilled  water,  300.  (f  3v)  ; 


518  CYCLOPLEGICS. 

Or 

Duboisin  sulphate,  1.  (gr.  j); 

Distilled  water,  240.  (f  siv). 

The  above  are  used  as  the  cycloplegic  atropin  solutions, 
one  drop  in  the  eye  three  times  a  day. 

Scopolamin  hydrobromate,  1.  (gr.  ss) ; 

Distilled  water,  1000.  (f  sj) ; 

is  used  like  the  homatropin  solution,  two  or  three  drops 
being  instilled,  a  drop  at  a  time  with  intervals  of  five  or 
ten  minutes.  Hyoscyamin  and  duboisin  may  be  used 
similarly.  If  carefully  applied,  complete  paralysis  of 
accommodation  is  thus  produced,  with  less  risk  of  consti- 
tutional symptoms  than  with  stronger  solutions,  and 
recovery  occurs  in  from  four  to  seven  days. 

Stronger  solutions  are  required  to  break  up  adhe- 
sions of  the  iris  to  the  lens-capsule,  and  to  maintain  dila- 
tation of  the  pupil  in  iritis  as : 

Atropin  sulphate,  1.  (gr.  j)  ; 

Distilled  water,  60.  (f  3J). 
Or 

Hyoscyamin  hydrobromate,  1.  (gr.  j); 

Distilled  water,  120.  (f  sij). 

On£  of  these  is  to  be  instilled  every  five  minutes  until  the 
pupil  is  dilated,  or  until  symptoms  of  mydriatic  intoxica- 
tion begin  to  appear.  Eversion  of  the  puncta  will  hinder 
the  appearance  of  the  toxic  symptoms,  and  two  or  three 
instillations  of  a  5  per  cent,  solution  of  cocain  will  increase 
the  mydriatic  effect. 

Gelatin  Disks. — Homatropin  is  used,  associated 
with  cocain,  in  gelatin  disks.  Used  in  this  way  it  produces 
more  effect  than  the  same  amount  of  homatropin  used 
alone.  Each  disk  contains  usually  one-fiftieth  of  a  grain 
of  each  drug.  Two  disks  are  placed  in  the  eye,  fifteen  to 
thirty  minutes  apart  and  allowed  slowly  to  dissolve. 

Other  mydriatics  and  the  rnyotics  are  also  applied  in 
the  same  way.  But  the  gelatin  disks  are  not  generally  to 


REMEDIES  AND  THEIR  APPLICATIONS.         519 

be  preferred  to  solutions.  The  disks  or  lamellae  com- 
monly used  contain  : 

Homatropin  hydrobromate,  ^-^  or  -^  gr. ; 
Atropin  sulphate,  ^¥,  -gfa,  or  7 fa  gr. ; 

Cocain  hydrochlorate,  giro  or  Fff  £T'  > 

Physostigmin  sulphate,         y^  or  ^fa  gr. ; 
Pilocarpin  nitrate,  -sfa  gr. 

A  single  disk  may  be  used  instead  of  a  drop  of  one  of 
the  solutions  previously  mentioned. 

MYOTICS. 

Physostigmin  or  eserin  (sulphate  or  salicylate)  is  a 
powerful  myotic  capable  of  neutralizing  the  mydriatic 
influence  of  five  times  its  weight  of  homatropin.  In 
young  persons  it  can  cause  very  painful  cramp  of  the 
ciliary  muscle,  and  sphincter  of  the  pupil,  and  on  that 
account  must  be  used  with  caution.  For  instillation  in 
corneal  disease,  or  to  contract  the  pupil  after  simple 
extraction  of  cataract  it  may  be  used  in  solution  of 

Physostigmin  salicylate,  1 .  (gr.  ^) ; 

Distilled  water,  2000.  (f  3j). 

To  contract  the  pupil  in  glaucoma,  instillations  of  this 
solution  may  be  first  tried  ;  and  then  if  necessary  stronger 
solutions  may  be  employed  up  to  1  : 120  (gr.  iv  to  f  3j). 
The  weakest  solution  that  will  produce  moderate  contrac- 
tion of  the  pupil  is  the  one  to  be  chosen.  As  an  ocular 
tonic,  still  weaker  solutions  are  recommended  as 

Physostigmin,  1.  (gr.  ^)  ; 

Distilled  water,  10,000.  (f  gj). 

Pilocarpin  hydrochlorate  is  a  weak  myotic,  being 
able  to  neutralize  only  one-fourth  its  weight  of  homa- 
tropin. It  is  used  in  the  proportion  of 

Pilocarpin  hydrochlorate,  1.  (gr.  j)  ; 

Distilled  water,  500.  (f  Ij). 

It  may  be  instilled  three  times  a  day  or  less  frequently 
to  contract  the  pupil  in  cortical  cataract,  or  as  a  local  tonic. 


520  LOCAL  APPLICATIONS. 

MISCELLANEOUS  SOLUTIONS. 

Extract  of  suprarenal  body  has  a  powerful  in- 
fluence in  causing  contraction  of  the  vessels  and  conse- 
quent anemia  of  the  conjunctiva. 

Extract  of  suprarenal  body,         1.  (gr.  xxjv); 
Distilled  water,  20.  (f  gj). 

After  maceration  for  a  few  minutes,  this  should  be  filtered. 
One  or  more  drops  may  be  instilled.  It  must  be  freshly 
prepared. 

Fluorescin  solution  is  used  to  detect  the  location 
and  extent  of  corneal  ulcers.  It  contains 

Fluorescin,  •     1. 

Sodium  bicarbonate,  2. 

Distilled  water,  100. 

A  drop  of  this,  placed  in  the  conjunctival  sac,  quickly 
stains  green  all  tissue  exposed  by  the  loss  of  epithelium. 

DRUGS  USED  FOR  THEIR  SYSTEMIC  INFLUENCE. 

Mercury  most  quickly  produces  its  specific  effects 
when  given  by  inunction.  Mercurial  ointment  (unguentum 
hydrargyri,  50  per  cent,  of  metallic  mercury)  should  be 
rubbed  into  the  thinner  parts  of  the  skin,  to  the  amount 
of  2  to  4  grammes  (sss  to  j),  once  or  twice  daily.  For 
exactness,  it  may  be  prescribed  with  each  dose  separately 
wrapped  in  waxed  paper.  The  rubbing  should  be  with 
the  slightest  friction,  and  is  best  done  with  a  glass  rod. 
It  should  be  continued  until  the  ointment  has  largely  dis- 
appeared, at  least  fifteen  minutes.  If  the  friction  causes 
irritation,  the  inunction  should  not  be  repeated  upon  the 
same  part  for  two  or  three  days. 

Calomel  is  the  best  form  in  which  to  give  mercury 
when  it  is  desirable  to  obtain  a  purgative,  as  well  as  a 
specific,  effect.  It  is  given  in  doses  of  1  centigramme 
(gr.  l)  every  two  to  six  hours. 

The  administration  of  mercury  should  be  promptly 
suspended  on  the  appearance  of  evidence  of  its  action 


REMEDIES  AND  THEIR  APPLICATIONS.         521 

about  the  mouth.  After  these  symptoms  have  subsided, 
one  of  the  following  slower  methods  may  be  resorted  to : 

The  yellow  iodid  (green  iodid)  is  best  given  in  pill,  in 
doses  of  ^  to  2  grains,  three  times  a  day,  often  combined 
with  opium. 

Corrosive  sublimate  (mercuric  chlorid)  may  be  given 
in  solutions  of  potassium  iodid  (which  it  converts  into  the 
red  iodid  of  mercury),  in  doses  of  ^  to  ^  of  a  grain, 
three  times  a  day. 

Mercury  may  also  be  given  hypodermically,  or  by  deep 
intramuscular,  or  intravenous  injections,  once  every  two  or 
three  days.  These  are  to  be  resorted  to  when  other 
methods  of  administration  fail  to  check  the  disease,  or 
provoke  serious  mercurial  symptoms. 

Potassium  iodid,  to  be  effective  in  the  lesions  of 
tertiary  syphilis,  or  in  optic  neuritis,  must  be  given  in 
large  doses.  The  rule  is  to  commence  with  a  dose  of  10 
or  15  grains,  given  three  or  four  times  a  day,  and  to 
rapidly  increase  the  dose  until  the  desired  eifect  is  pro- 
duced, or  the  physiologic  action  of  the  drug  is  manifest. 
This  is  conveniently  managed  by  giving  the  patient  the 
drug  in  concentrated  solution, 

Potassium  iodid,  1. 

Distilled  water,  2.  (f 

beginning  with  twenty  or  thirty  drops,  and  adding  two 
drops  to  the  dose  each  day,  or  at  each  dose,  according  to 
the  urgency  of  the  case.  When  the  coryza,  gastric  dis- 
turbance, eruption,  or  persistent  taste  of  the  drug  is 
noticed,  its  administration  may  be  suspended  for  a  day  or 
two,  and  then  resumed  in  slightly  diminished  dose. 

Strychnin,  when  given  for  toxic  amblyopia  or  optic 
atrophy,  is  most  effective  administered  in  ascending  doses, 
or  those  approaching  the  physiological  limit.  It  is  most 
safely  given  in  solution,  or  in  carefully  prepared  granules. 
Commencing  with  a  dose  of  -^  of  a  grain,  this  may,  from 
time  to  time,  be  increased  to  •£$,  -fa,  -^,  -fa,  and  some- 
times to  -|-,  ^,  or  even  1  of  a  grain,  three  times  a  day. 
The  patient  must  be  kept  on  his  guard  against  an  exces- 


522  SYSTEMIC  REMEDIES. 

sive  dose ;  and  each  time  a  new  solution  is  prescribed  the 
dose  should  be  at  first  slightly  diminished.  When  ,-t ill- 
ness of  the  neck  or  jaws  is  noticed,  or  ordinary  movements 
produce  unpleasant  jerking  within  an  hour  or  two  after 
the  taking  of  the  medicine,  the  dose  should  be  slightly 
diminished. 

Hypodermically,  the  dose  is  about  the  same  as  by  the 
mouth,  but  it  is  administered  only  once  a  day.  It  is 
gradually  increased  from  day  to  day  until  the  limit  of 
tolerance  is  reached. 

Pilocarpin,  given  to  produce  sweating,  in  detachment 
of  the  retina,  choroiditis,  and  vitreous  opacity,  is  best 
administered  hypodermically.  From  2  to  10  minims  of 
the  following  solution  are  injected  : 

Pilocarpin  hydrochlorate  (or  nitrate),  1.  (gr.  ij) ; 
Distilled  water,  30.  (f  3J). 

The  patient  is  then  kept  warmly  covered  up  in  bed  for 
three  or  four  hours.  This  may  be  repeated  daily. 

BIBLIOGRAPHY. 

Ophthalmological  Therapeutics.  Landolt  and  Gygax,  138  pp.  The 
J.  B.  Lippincott  Co.,  Philadelphia. 

Ocular  Therapeutics.  F.  W.  M.  Ohlemann.  Edited  by  C.  A.  Oliver, 
280  pp.  P.  Blakiston's  Son  &  Co.,  Philadelphia. 

Use  of  Protargol.  B.  Wicherkiewicz,  "  Araer.  Jour,  of  Ophthal- 
mology," Jan.,  1899. 

Subconjunctival  Injections.  A.  Marti,  C.  Mellinger,  D.  Bossalino, 
L.  Bach,  "Ophthalmic  Review,"  July,  1895. 

Subconjunctival  Injections.  E.  J.  Bernstein,  "  Trans.  Sect,  on  Oph- 
thalmol.,  Amer.  Med.  Assoc.,"  1896. 

Intra  ocular  Injections  of  Antiseptics.  G.  E.  de  Schweinitz,  "  Trans. 
Sect,  on  Ophthalmol.,  Amer.  Med.  Asspc.,"  1893. 

The  Use  of  Extract  of  Supra-renal  Capsule  in  the  Eye.  W.  H.  Bates, 
"New  York  Med.  Jour.,"  May  1(5,  1898. 

Hypodermic  Use  of  Pilocarpin.  G.  H.  Burnham,  "Archives  of 
Ophthalmology,"  March,  1898. 

Treatment  of  Syphilis  of  the  Eye  by  Intravenous  Injections  of  Mer- 
cury. Jehin-Prume,  "  Ophthalmic  Review,"  Oct.,  1897. 


COMMON  OPERATIONS.  523 

CHAPTER   XIX. 

COMMON  OPHTHALMIC  OPERATIONS. 

GENERAL  CONSIDERATIONS. 

Preparation  of  the  Patient. — For  office  operations 
the  eye  should  be  thoroughly  cleansed  with  boric  acid 
solution,  the  lids,  lashes,  and  adjoining  parts  of  the  face 
having  been  previously  scrubbed  with  soap  and  water. 
If  there  be  lacrimal  or  other  septic  disease  it  should 
generally  be  treated  first.  But  in  emergency-operations, 
as  removing  a  foreign  body,  or  iridectomy  for  prolapse 
of  the  iris,  we  may  have  to  be  content  with  thoroughly 
washing  out  the  lacrimal  passages  before  cleansing  the 
eye.  A  weak  solution  of  mercuric  chlorid,  1  : 5000, 
may  be  used  for  this  purpose,  but  thoroughness  in  the 
washing  is  to  be  mainly  relied  on. 

House  patients  should  be  accustomed  to  their  sur- 
roundings, spending  one  day  in  the  hospital  before  the 
operation,  should  have  the  bowels  freely  opened,  a  general 
bath,  and  the  conjunctiva  cleansed  repeatedly  with  boric- 
acid  solution.  The  lids  and  neighboring  parts  and, 
especially  the  lid-margins  and  lashes,  should  be  thoroughly 
cleansed  with  soap  and  water.  Any  conjunctivitis  should 
be  treated  until  the  eye  is  free  from  discharge  or  undue 
redness,  before  undertaking  a  cataract  or  plastic  opera- 
tion. In  cases  of  lacrimal  disease  that  cannot  otherwise 
be  cured,  it  may  be  best,  as  a  preliminary  measure  to 
obliterate  the  lacrimal  sac.  When  there  is  lacrimal 
disease,  and  no  time  to  treat  it,  as  in  acute  glaucoma,  the 
sac  may  be  thoroughly  washed  out  and  the  puncta  tem- 
porarily obliterated  by  touching  them  with  the  actual  or 
galvanic  cautery.  They  can  be  reopened  after  the  heal- 
ing of  the  corneal  wound.  Operations  that  can  be 
delayed  should  not  be  done  during  acute  bronchitis,  or 
temporary  depression  of  the  general  health  from  any 
cause.  But  extreme  age,  or  feeble  health  is  rarely  a 
positive  bar  to  success  in  ophthalmic  operations. 


524  PREPARATION  FOR   OPERATING. 

Preparation  of  the  Surgeon. — Septic  cases  should 
not  be  seen  for  several  hours  before  operating.  The 
hands  of  the  operator  and  his  assistants  should  be 
thoroughly  scrubbed  with  soap  and  hot  water,  the  nails, 
etc.,  carefully  cleaned,  and  the  scrubbing  repeated.  They 
must  then  be  kept  from  touching  surfaces  that  have  not 
been  rendered  similarly  aseptic. 

If  the  operation  is  one  not  frequently  done,  the  operator 
should  go  carefully  over  every  step  of  it  in  mental  review, 
or  previously  practice  it  on  the  eyes  of  lower  animals. 
He  should  see  that  every  instrument  and  appliance  is  in 
place,  carefully  try  the  light  that  is  to  be  used,  and 
adjust  seat  or  position  so  that  every  necessary  movement 
may  be  made  with  the  greatest  ease  and  freedom,  and 
without  danger  of  jostling.  When  operating  without  an 
accustomed  assistant,  it  is  best  to  have  all  instruments 
within  the  surgeon's  reach  and  to  make  the  temporary 
assistant's  duties  as  few  and  definite  as  possible. 

Preparation  of  the  Instruments,  etc. — After  use, 
and  before  it  has  had  time  to  dry,  every  instrument 
should  be  carefully  cleaned  with  hot  soap  and  water, 
special  attention  being  given  to  all  joints,  and  to  rough 
instruments  to  insure  that  they  retain  no  mass  or  clot 
of  infective  matter.  This  should  be  attended  to  by  the 
surgeon  himself,  or  a  specially  trained  nurse  or  assistant. 
The  instruments  should  be  kept  in  a  tight  case,  with 
powdered  paraform,  which  gives  off  constantly  formal- 
dehyd  vapor.  Instruments  used  for  cases  of  suppura- 
tion and  trachoma  should  be  kept  separate  from  those 
used  for  aseptic  operations.  Before  using,  the  instru- 
ments should  be  again  washed,  and  the  jointed  and  rough 
instruments  boiled  for  two  minutes.  Knives  and  other 
cutting  instruments  are  to  be  dipped  in  boiling  water. 
The  instruments  may  remain  in  boiled  water,  or  can  be 
loosely  wrapped  in  sterile  absorbent  cotton  until  wanted. 

Another  method  is,  after  cleansing,  to  place  instruments 
that  cannot  be  boiled  in  a  solution  of  formaldehyd  5  to  20 
per  cent,  to  which  has  been  added  3  per  cent,  of  borax. 
In  this  they  remain  continuously  until  required  for  use. 


COMMON  OPERATIONS.  525 

They  are  then  rinsed  in  a  boric  acid  solution  and  wiped 
with  cotton  to  remove  any  deposit,  and  are  ready  for  use. 

Position  and  Illumination. — For  operating  on  the 
eye  the  patient's  head  should  be  about  as  high  as  the 
lower  part  of  the  surgeon's  chest,  firmly  supported,  and 
with  the  face  directed  upward.  This  position  may  for 
minor  operations  be  attained  in  a  chair,  the  head  resting 
on  a  head  rest,  or  against  the  surgeon's  chest.  But  for 
important  operations  it  is  best  secured  upon  a  table,  the 
height  of  which  must  be  adjusted  according  as  the 
surgeon  prefers  to  sit  or  stand  while  operating.  In  oper- 
ating upon  a  bed,  the  patient  must  be  so  that  the  head  of 
the  bedstead  will  not  interfere,  as  across  the  bed  or  with 
his  head  toward  the  foot  of  the  bed.  The  head  must  be 
supported  on  a  firm  hair  pillow  under  which  a  board  may 
be  placed  to  give  additional  steadiness. 

Generally  the  light  should  come  from  the  side  of  the 
eye  operated  on.  The  best  light  is  the  brightest  that  can 
be  obtained  short  of  direct  sunlight,  coming  from  rather  a 
small  space,  and  in  such  direction  that  the  surgeon  shall 
not  be  baffled  by  annoying  reflections  from  the  cornea. 
The  conditions  to  be  met  are  essentially  those  of  a  good 
oblique  illumination.  An  electric  lamp  furnished  with 
shade  and  condenser  is  the  most  manageable  source.  But 
with  the  patient  brought  close  to  a  window  that  opens  to 
clear  sky,  an  excellent  illumination  can  be  arranged  by 
diffuse  daylight.  The  patient  should  be  brought  into 
position,  and  the  light  carefully  tested  and  adjusted  before 
beginning  the  operation. 

Retraction  of  the  I/ids  and  Fixation  of  the  Eye- 
ball.— The  patient  should  steadily  fix  his  gaze  upon  the 
proper  designated  spot ;  and  by  so  doing  he  will  lessen  the 
discomfort  of  operations  done  without  general  anesthesia. 
For  many  operations  retraction  of  the  lids  and  fixation 
are  best  accomplished  with  the  operator's  left  hand. 
Standing  behind  the  patient,  the  fore-finger  retracts  the 
skin  of  the  upper  lid,  and  fixes  it  by  pressure  against  the 
upper  margin  of  the  orbit ;  while  the  middle-jinger 
similarly  fixes  the  lower  lid  against  the  lower  orbital 


526  RETRACTION  OF  LIDS. 

margin.  This  secures  retraction  of  the  lids  without  pres- 
sure on  the  globe,  and  the  traction  on  the  conjunctiva 
tends  to  steady  the  globe.  To  fix  the  globe  more  firmly, 
pressure  must  be  made  with  the  fingers  above  and  below 
the  cornea. 

When  the  left  hand  will  be  otherwise  employed,  the 
lids   must  be   retracted   by   a   stop-speculum,  which   is 


FIG.  151. — Stop-speculum. 

slipped  between  them  and  then  opened  as  widely  as  it 
can  be  without  causing  pain.  The  best  form  is  shown  in 
Fig.  151.  Or  the  lids  may  be  retracted  by  an  assistant 
using  for  the  upper  lid  a  retractor  such  as  is  shown  in 
Fig.  152.  To  protect  the  eyeball  during  operations  on 
the  lids  the  lid-spatula  shown  in  Fig.  156  is  employed. 


FIG.  152.— Lid-retractor. 


When  pressure  on  the  globe  must  be  avoided  fixation- 
forceps  (Fig.  153)  must  be  used.  For  use  on  the  con- 
junctiva their  jaws  should  be  serrated  rather  thafi  toothed, 


FIG.  153.— Fixation-forceps  for  seizing  the  conjunctiva. 

and  they  are  to  be  applied  as  close  to  the  limbus  as  pos- 
sible where  the  conjunctiva  is  most  firmly  connected  with 
the  sclera.  They  should  make  no  pressure  on  the  globe. 


COMMON  OPERATIONS.  527 

For  siezing  upon  the  firm  deeper  tissues,  fine-toothed  for- 
ceps are  made  (Fig.  154). 

Sponging  for  eye  operations  is  best  done  with  masses 
of  absorbent  cotton  moistened  with  boric  acid   solution, 


FIG.  154.— Fixation-forceps  for  holding  deeper  firm  tissues. 

and  then  squeezed  dry  as  possible.  These  may  be 
wrapped  on  sticks  six  or  eight  inches  long,  before  moist- 
ening, to  enable  the  assistant  to  keep  his  hands  out  of  the 
way.  Blood  may  also  be  washed  away  with  solutions  of 
boric  acid  or  common  salt. 

DRESSINGS. 

Simple  Dressing1. — To  give  the  eye  rest,  protect  it 
from  slight  temperature  changes,  exclude  mechanical, 
chemical  and  bacterial  irritants,  and  provide  for  the 
absorption  of  the  slight  discharge  that  escapes  between 
the  lids  with  the  least  discomfort,  without  pressure  and 
without  undue  local  heat,  are  the  indications  to  be  met 
by  the  dressings  after  an  ophthalmic  operation. 

The  author  most  frequently  employs  the  following :  A 
few  layers  of  gauze,  large  enough  to  cover  the  orbit,  are 
laid  upon  the  closed  lids,  and  on  these  a  sufficient  mass 
of  absorbent  cotton.  This  is  retained  by  one  or  more 
strips  of  adhesive  plaster,  one  inch  wide,  extending  from 
the  center  of  the  forehead  to  the  cheek,  with  perhaps  one 
strip  from  the  temple  to  the  opposite  side  of  the  nose. 

If  the  other  eye  is  to  be  closed  a  similar  dressing  is  to 
be  placed  over  it.  If  it  is  desired  to  have  a  moist  dress- 
ing, the  gauze  may  be  covered  with  surgical  lint  dipped 
in  boric  acid  or  other  solution,  and  a  layer  of  oiled  silk 
or  rubber  protective  added  over  the  cotton.  When  it  is 
important  that  the  lashes  should  not  stick  to  the  dressing, 
it  may  be  smeared  with  soft  petrolatum,  or  boric  acid 
ointment. 


528  DRESSINGS. 

Pressure-bandage. — When  required,  pressure  is  made 
by  means  of  a  bandage.  A  large  wad  of  absorbent  cotton 
is  carefully  adjusted  to  properly  distribute  the  pressure ; 
then  a  roller  of  elastic  flannel,  2  inches  wide  and  5 
yards  long,  is  started  upon  the  occiput,  carried  under  the 
mastoid  and  ear  on  the  side  of  the  affected  eye,  up  over 
the  eye,  high  on  the  temporal  region  of  the  side  of  the 
head,  and  down  to  the  point  of  starting.  The  bandage 
will  be  most  firm  if  every  alternate  turn  is  carried  above 
the  ear  on  the  affected  side  and  low  on  the  opposite  side 
of  the  head.  It  should  be  pinned  at  the  points  of  inter- 
section. The  bandage  will  not  retain  its  position  well 
unless  it  does  make  some  pressure.  It  is  therefore  un- 
suitable for  use  after  many  operations. 

To  secure  simple  closure  of  the  lids,  isinglass  plaster  is 
used.  A  strip  of  the  plaster  ^  inch  wide  is  placed  on 
the  palpebral  fissure,  and  one  or  more  strips  at  right 
angles  to  this,  extending  from  just  under  the  brow  down 
to  the  cheek.  This  dressing,  when  dry,  is  likely  to  cause 
some  discomfort.  Only  the  thinnest  and  most  flexible 
plaster  answers  the  purpose  properly. 

Ring  Dressing. — After  plastic  operations,  especially 
after  skin-grafting,  it  is  best  to  make  a  ring  of  absorbent 
cotton,  large  enough  to  include  the  whole  field  of  opera- 
tion, and  thick  enough  to  support  the  dressing  without  its 
coming  in  contact  with  the  new-formed  surface. 

The  I<iebreich  bandage  was  originally  a  light 
knitted  bandage  secured  by  tapes ;  but  the  name  has 
come  to  be  applied  to  various  forms  of  thin  bandage 
fastened  by  tapes.  It  may  be  single  (for  one  eye)  or 
double  (for  both  eyes).  It  is  convenient,  when  the  dress- 
ing must  be  removed  frequently  to  instil  drops  or  to 
cleanse  the  eye. 

Mask  Protector. — To  protect  the  eye  from  injury 
by  accidental  strokes  during  sleep,  as  after  cataract  ex- 
traction, a  woven  wire  mask,  or  aluminum  protector,  is 
sometimes  used. 

Eye-shades  should  be  light,  and  allow  sufficient  air 
to  enter  around  them  to  keep  the  covered  eye  cool  and 


COMMON  OPERATIONS.  529 

dry.  A  nice  one  is  made  of  aluminum  covered  with 
silk.  Buller's  shield,  to  exclude  infection  while  permit- 
ting the  use  of  the  eye,  is  described  on  page  249. 

HEMOSTASIS. 

In  ophthalmic  operations  and  for  wounds  about  the  eye, 
it  is  rarely  needful  to  ligate  bleeding  vessels.  Pressure 
soon  controls  bleeding ;  so  does  hot  water  (see  page  503). 
Solutions  of  cocain  greatly  diminish  the  bleeding  when 
that  drug  is  used  as  a  local  anesthetic.  This  action  adds 
greatly  to  the  value  of  cocain  for  operations  for  ptery- 
gium,  squint,  etc.,  where  bleeding  may  cause  embarrass- 
ment. Hydrogen  dioxid  quickly  checks  bleeding,  but  as 
the  froth  it  makes  would  equally  embarrass  the  operator, 
it  generally  cannot  be  used  until  the  close  of  the  opera- 
tion. Extract  of  suprarenal  body  applied  before  pro- 
ceeding to  an  operation  will  greatly  diminish  the  bleeding. 

ABSTRACTION    OF  BLOOD. 

The  loose  tissue  of  the  lids  is  so  liable  to  excessive 
swelling  after  a  leech-bite,  that  leeches  are  usually  applied 
to  the  temple,  which  may  be  pricked  until  blood  appears 
to  induce  them  to  bite.  Each  American  leech  will  draw 
about  one  fluid-dram  of  blood,  the  European  leech  four 
times  as  much. 

The  artificial  leech  consists  of  a  circular  knife  made  to 
cut  with  a  rotary  movement ;  and  a  glass  cylinder  that 
can  be  exhausted  of  air  by  a  screw-piston.  From  one  to 
four  ounces  of  blood  may  be  taken  from  the  temple  with 
advantage.  In  severe  ocular  inflammations  this  may 
give  more  relief  from  pain  than  any  other  measure. 

OPERATIONS  UPON  THE  LIDS. 

The  removal  of  displaced  lashes  is  commonly 
effected  with  forceps  such  as  are  shown  in  Fig.  155.  The 
tips  should  close  upon  one  another  with  perfect  accu- 
racy. To  see  the  fine  white  lashes  which  are  most  fre- 
quently at  fault,  oblique  illumination  should  be  employed. 

34 


530 


REMOVAL  OF  LASHES. 


The  binocular  magnifier  mounted  on  a  head-band  is  also 
of  great  assistance  (see  page  69). 

For  the  permanent  destruction  of  the  lashes,  electro- 


FIG.  155.— Epilation-forceps. 


lysis  is  to  be  practiced  by  thrusting  a  fine  needle,  con- 
nected with  the  negative  pole  of  the  battery,  as  accurately 
as  possible  to  the  root  of  the  hair  (the  positive  pole  being 


FIG.  156.— Making  the  intermarginal  incision  (Hotz). 

held  in  the  hand),  and  allowing  a  current  of  2  or  4  milli- 
amperes  to  pass  through  it  for  five  to  twenty  seconds. 
Minute  bubbles  of  gas  escape,  and  the  hair  should  be 
found  loose  in  its  follicle. 


COMMON  OPERATIONS.  531 

When  the  lid  has  become  greatly  distorted  by  cicatri- 
cial  changes,  as  after  trachoma,  so  that  restoration  of  the 
lid-margin  to  good  position  is  impossible,  the  best  result 
may  be  obtained  by  excision  of  the  hair-bulbs,  "  scalping." 
The  "  intermarginal  incision"  (see  Fig.  156)  is  made  just 
back  of  the  hair-bulbs,  and  another  incision  parallel  to  it, 
and  2  or  3  mm.  above  it,  on  the  surface  of  the  lid.  The 
strip  of  tissue  between,  including  the  hair-bulbs,  is  re- 
moved, and  the  skin  and  conjunctiva  brought  together  by 
fine  sutures.  The  tract  is  dusted  with  iodoform  and 
the  eye  covered  with  a  light  dressing. 

Operations  for  entropion  and  distichiasis,  bear- 
ing the  names  of  their  originators  and  modifiers,  are  suffi- 
ciently numerous.  And  several  of  them  possess  parti- 
cular advantages  for  certain  cases.  The  most  generally 
applicable  for  entropion  of  the  upper  lid  is  the  following : 
The  upper  lid  is  put  upon  the  stretch,  and  an  incision  is 
made  parallel  to  the  lid-margin,  and  so  far  below  the 
upper  border  of  the  cartilage  that  when  drawn  up  to  it 
the  lid-border  will  be  pulled  upon  sufficiently  to  evert  all 
the  lashes.  The  tissue  covering  the  cartilage,  including 
the  fibers  of  the  orbicularis  muscle,  is  then  carefully 
removed.  The  skin  attached  to  the  lid-margin  is  then 
drawn  up  and  fastened  to  the  upper  margin  of  the  carti- 
lage by  three  sutures,  which  are  afterward  carried  through 
the  other  lip  of  the  wound,  which  is  thus  closed.  Iodo- 
form is  dusted  on  the  line  of  incision  and  the  whole  cov- 
ered with  a  light  dressing.  After  four  or  five  days  the 
sutures  are  removed  and  all  dressings  omitted. 

If  such  a  readjustment  would  cause  much  tension  on 
the  skin  of  the  lid-margin,  it  is  well  to  begin  by  making 
the  "  intermarginal  incision "  behind  all  the  lashes ;  and 
when  this  is  made  to  gape,  by  tightening  the  sutures  that 
close  the  incision  at  the  upper  border  of  the  cartilage,  to 
transplant  into  it  a  strip  of  skin  from  behind  the  ear, 
which,  being  cut  in  the  shape  of  a  deep  wedge  and 
pressed  into  the  incision,  will  remain  in  position  without 
sutures.  This  is  essentially  the  method  of  Hotz. 

Entropion  of  the  lower  lid  due  to  redundant  skin  is 


532  ENTROPION  OPERATIONS. 

relieved  by  excision  of  an  appropriate  piece  of  skin  and 
the  bringing  it  together  with  sutures,  or  by  producing 
cicatrieial  contraction  of  the  skin  with  caustic  potash  (see 
page  456). 

Canthotomy  is  done  to  extend  temporarily  the  pal- 
pebral  fissure,  to  prevent  irritating  pressure  and  secure 
more  complete  eversion  of  the  lids  in  conjunctivitis,  or 
for  the  relief  of  fissure  of  the  skin  at  the  outer  canthus. 
One  blade  of  a  pair  of  strong  blunt-pointed  scissors  is 
introduced  into  the  conjunctiva!  sac  at  the  outer  canthus, 


FIG.  157.— Canthoplasty  (Meyer). 

the  other  blade  being  placed  on  the  skin  near  the  margin 
of  the  orbit.  The  inner  blade  must  be  made  to  press  ex- 
actly into  the  canthus,  so  as  not  to  cut  either  lid ;  and 
while  the  lids  are  stretched  apart  with  the  thumb  and 
finger,  the  tissues  are  divided  at  a  single  stroke.  The 
incision  may  also  be  made  with  a  scalpel  or  bistoury. 

Canthoplasty  is  done  to  permanently  extend  the  pal- 
pebral  fissure.  After  the  incision  for  canthotomy  above 
described,  the  conjunctiva  and  skin  are  brought  together, 
so  as  to  cover  the  raw  surfaces  and  prevent  their  reunion. 


COMMON  OPERATIONS.  533 

Three  sutures  are  required.  One  is  placed  at  the  ter- 
mination of  the  incision,  the  extreme  angle  between  the 
lids,  where  it  is  most  important  to  secure  accurate  junc- 
tion of  the  skin  and  conjunctiva,  and  one  on  either  side 
of  this  on  the  upper  and  lower  lids.  The  sutures  should 
take  a  good  hold  on  the  conjunctiva,  emerge  near  the 
conjunctival  edge  of  the  raw  surface,  re-enter  near  the 
skin-margin,  and  take  a  good  hold  on  the  skin  without 
much  of  the  deeper  tissures.  The  cut  with  the  stitches 
introduced  is  shown  in  Fig.  157.  It  is  sometimes  well 
to  undermine  the  skin  somewhat  to  make  it  closely  meet 
the  conjunctiva.  lodoform  may  be  dusted  upon  the 
wound  and  a  light  dressing  applied  to  cover  it. 

The  effect  of  a  canthoplasty  may  be  increased  by  divi- 
sion of  the  tarsal  ligament.  This  is  put  upon  the  stretch 
by  pulling  the  upper  lid  toward  the  nose,  and  then 
divided  by  fine-pointed  scissors,  the  points  being  in- 
troduced between  the  skin  and  conjunctiva  directly 
upward. 

Division  of  the  upper  lid  is  practised  to  relieve 
pressure  and  facilitate  the  treatment  of  purulent  ophthal- 
mia, or  to  facilitate  plastic  operations  in  the  upper  con- 
junctival sac,  and  prevent  subsequent  displacement. 
With  blunt  strong  scissors  the  lid  is  divided  vertically 
near  its  center,  and  each  flap  is  turned  up  and  stitched  to 
the  brow  by  a  suture  passing  through  its  angle.  After 
the  purpose  of  the  operation  has  been  served,  the  edges 
of  the  lid  are  freshened  and  carefully  brought  together 
with  fine  sutures. 

Union  of  the  lids  (tarsorrhaphy)  may  be  done  at  the 
outer  canthus  to  shorten  the  palpebral  fissure,  for  passive 
ectropion  of  the  lower  lid,  or  lagophthalmos.  For  this 
purpose  the  lids  are  drawn  together  as  desired  and  the 
point  for  the  new  canthus  marked  on  each.  From  this 
point  outward,  a  narrow  strip  of  tissue,  containing  the 
bulbs  of  the  lashes,  is  removed  from  each  lid.  This  strip 
may  include  more  of  the  skin-surface  of  the  upper  lid 
and  more  of  the  conjunctival  surface  of  the  lower.  The 
two  lids  are  then  brought  accurately  together  by  sutures, 


534  UNION  OF  THE  LIDS. 

which  must  include  the  thickness  of  the  lid  and  be  left 
in  place  until  union  is  firm. 

To  protect  the  cornea  in  exophthalmic  goitret  the  cen- 
tral portion  of  the  lids  may  be  united.  In  this  case  the 
lashes  are  left,  in  the  hope  that  union  need  be  only  tem- 
porary. The  freshened  surface  includes  not  less  than 
half  of  the  inner  edge  of  the  lids ;  and  the  stitches  must 
be  deep  and  well  drawn  up  to  secure  a  sufficiently  firm 
union,  to  be  of  any  value. 

To  secure  immobility  of  the  parts  for  a  few  days,  as 
after  a  wound  or  plastic  operation  on  the  lids,  the  lid- 
margins  may  be  stitched  together  without  freshening  their 
edges,  care  being  taken  to  avoid  the  rubbing  of  the 
stitches  against  the  cornea. 

Ectropion  Operations. — Ectropion,  due  to  thicken- 
ing of  the  conjunctiva,  usually  affects  the  lower  lid.  It 
may  be  treated  by  removal  of  the  conjunctival  and  sub- 
conjulictival  tissue  by  a  V-shaped  incision  and  bring- 
ing the  edges  together  by  sutures.  If  the  deformity  be 
too  great  for  that,  the  incision  may  include  the  whole 
thickness  of  the  lid  and  should  be  brought  together  with 


FIG.  158.— Argyll  Robertson's  strap-operation  for  ectropion  of  the  lower  lid. 

a  fine  hare-lip  pin  and  sutures.  A  safer  operation,  if 
applicable,  is  the  removal  of  a  triangular  piece  at  the 
outer  end  of  the  lid  with  the  formation  of  a  strap  run- 
ning up  on  the  temple,  as  illustrated  in  Fig.  158.  The 
strap  is  first  cut  as  indicated  by  the  heavy  line,  then  the 
triangle  included  by  the  dotted  lines  is  excised  and  the 
lid  drawn  up  in  place  by  the  strap  and  the  piece  of  skin 


COMMON  OPERATIONS.  535 

covered  by  the  strap  (see  broken  line)  is  removed.  The 
parts  are  then  brought  together  with  sutures.  Ectropion, 
through  the  dragging  of  scar-tissue,  requires  some  form 
of  plastic  operation. 

Plastic  Operations  on  the  I/ids. — The  replace- 
ment of  tissue  to  remedy  distortion  of  the  lids  caused  by 
loss  of  tissue  gives  scope  to  the  widest  experience  and 
the  most  ingenious  adaptation  of  means  to  ends.  It 
should  be  undertaken  only  after  careful  study  of  many 
different  plans  of  procedure,  since  any  of  these  may  give 
hints  of  especial  value  in  the  particular  case.  It  is  here 
only  possible  to  indicate  a  few  general  principles.  A  suc- 
cessful result  can  only  be  attained  by  permanently  reliev- 
ing the  lids  of  all  abnormal  tension.  They  have  no  sup- 
port that  enables  them  to  resist  even  a  slight  continuous 
traction.  Skin  to  replace  the  lids  must  be  extremely . 
thin  and  flexible,  or  the  operation  substitutes  one  deform- 
ity for  another.  On  this  account,  skin  from  the  imme- 
diate vicinity  of  the  lids,  or  from  the  temple,  is  better 
than  from  other  parts.  Cicatricial  skin,  if  its  vitality  is 
good,  is  also  well  suited  for  the  purpose  (Hotz).  The  de- 
sirable skin  may  be  brought  in  by  sliding  flaps.  The  full 
thickness  of  the  skin  may  be  transplanted  without  pedicle 
from  distant  parts,  as  the  inner  surface  of  the  arm,  but 
there  is  a  liability  of  subsequent  shrinkage  of  the  flap. 
The  most  generally  applicable  method  is  that  of  trans- 
planting large  epithelial  skin-grafts,  proposed  by  Thiersch. 
This  should  be  used  to  cover  all  raw  surfaces  in  the 
vicinity  of  the  lids  which  may  cause  subsequent  de- 
formity. 

Epithelial  Grafts  (Thiersch  Grafts).— The  surface 
to  be  covered  should  be  free  from  granulations,  and  asep- 
tic. The  skin  from  which  the  graft  is  taken,  commonly 
the  inner  surface  of  the  arm,  is  carefully  cleansed  with- 
out the  use  of  any  strong  antiseptic.  The  skin  is  put 
upon  the  stretch  and  a  shaving  removed  with  a  sharp 
razor.  The  razor-blade  must  be  flooded  with  salt-solu- 
tion, to  float  the  graft  and  prevent  it  from  being  broken. 
A  graft  slightly  larger  than  the  surface  to  be  covered  is 


536 


EPITHELIAL   GRAFTS. 


most  desirable.  It  is  floated  from  the  razor  into  position, 
and  trimmed  to  the  exact  size  of  the  raw  surface  with 
scissors.  The  field  of  operation  is  then  to  be  protected 
by  a  ring  dressing  (page  528),  kept  warm  and  moist 
with  a  layer  of  protective,  and  left  undisturbed  for  two 
or  three  days. 

Ptosis  Operations. — Where  ptosis  is  due  to  hyper- 
trophy of  the  skin  or  other  tissues  of  the  lid,  the  tissue 
obstructing  lid-movements  is  to  be  excised.  If  the  con- 
tractile power  of  the  elevator  of  the  lid  is  lacking,  exci- 
sion of  a  strip  of  the  orbicularis  muscle,  or  of  the  muscle 
with  the  skin  over  it,  or  even  including  a  part  of  the 
tarsal  cartilage,  may  be  of  benefit.  But  if  the  loss  of 


FIG.  159.— Panas'  operation  for  ptosis  (Hotz). 

power  in  the  elevator  be  complete,  such  excisions  do  little 
good.  The  connection  of  the  lid  with  the  frontalis  mus- 
cle, so  that  by  its  action  the  lid  can  be  elevated,  is  then 
to  be  aimed  at.  This  end  has  been  sought  by  the  forma- 
tion of  a  subcutaneous  cicatrix  by  introducing  a  ligature 
extending  from  the  brow  to  the  lid-cartilage  and  allow- 
ing it  to  cut  its  way  out.  Panas  has  made  the  connection 
by  a  tongue  of  skin  drawn  up  under  the  bridge  of  tissue 
dissected  up  from  the  brow  as  indicated  by  Fig.  159. 
Mules  introduced  gilded  iron  wire  from  the  tarsal  cartil- 
age to  the  brow,  which  he  left  permanently  in  the  lid. 


COMMON  OPERATIONS.  537 

Chalasion  is  excised  by  making  an  incision  through 
the  skin  over  it,  parallel  to  the  lid-margin,  and  carefully 
dissecting  it  out.  The  operation  is  facilitated  by  the  use 
of  a  lid-clamp,  to  prevent  hemorrhage.  The  incision  is 
closed  with  a  fine  suture.  This  operation  is  rather  tedi- 
ous and  quite  painful. 

Incision  with  scraping  and  cauterization  is  a  shorter 
operation  and  mostly  preferable.  The  lid  is  everted  with 
the  lid-clamp  or  with  the  fingers.  The  discolored  spot 
on  the  conjunctival  surface  is  made  prominent,  and  freely 
excised  in  a  direction  perpendicular  to  the  lid-border. 
The  contents  are  then  scraped  out  with  a  curette,  and  the 
interior  of  the  cavity  touched  with  a  point  of  copper 
sulphate.  The  cavity  fills  with  blood,  which  may  require 
two  or  three  weeks  for  its  entire  removal. 


OPERATIONS  ON  THE  CONJUNCTIVA. 

Pterygfitim. — Small  pterygia  may  be  destroyed  by 
the  galvanic  cautery ;  or  by  electrolysis,  by  passing  a 
3  milliampere  current  for  one  minute  through  a  fine 
platinum  needle  thrust  under  the  growth,  parallel  to  the 
corneal  margin,  and  repeating  once  or  twice  with  the 
positions  of  the  needle  2  mm.  apart. 

Excision  begins  by  dissecting  up  the  pterygium,  and 
upon  the  thoroughness  with  which  this  is  done  depends 
chiefly  the  success  of  the  operation.  The  pterygium 
being  grasped  with  forceps  about  the  corneal  margin  is 
cut  loose  from  the  cornea  with  a  Beer's  knife,  care  being 
taken  to  go  deep  enough  to  leave  only  normal  corneal 
tissue,  especially  at  the  apex.  Prince  introduces  a  stra- 
bismus-hook beneath  the  pterygium,  and  with  it  tears  loose 
the  corneal  portion.  After  this  part  is  loosened  it  must 
be  seized  with  forceps  and  the  scleral  portion  dissected 
up,  the  same  care  being  used  to  remove  all  the  tissue 
down  to  the  sclera.  When  the  growth  has  been  dissected 
up,  incisions  are  made  at  the  upper  and  lower  margins, 
coming  together  near  the  caruncle.  The  conjunctiva 
may  then  be  brought  together  with  one  or  more  sutures, 


538  PTERYQIUM  OPERATIONS. 

but  should  not  be  made  to  cover  the  sclera  entirely  up  to 
the  corneal  margin. 

Transplantation. — With  the  scissors  a  cut  is  made  in 
the  conjunctiva  parallel  with  the  lower  nasal  margin  of 
the  cornea  and  about  8  mm.  from  it.  Into  this  slit  the 
pterygium,  after  being  dissected  up,  is  "  transplanted " 
by  a  stitch  fastening  its  apex  to  the  end  of  the  cut ;  or  if 
large  the  pterygium  may  be  split  in  halves  by  a  horizon- 
tal cut  with  the  scissors,  and  transplanted  one  half  above 
and  the  other  half  below  the  cornea.  Again,  both  ends 
of  a  thread  passed  through  the  apex  of  the  pterygium, 
may  be  carried  by  two  needles  beneath  the  conjunctiva 
and  brought  out  at  the  caruncle,  and  the  pterygium  thus 
folded  under.  When  thus  folded  or  transplanted  the 
growth  slowly  atrophies.  A  large  pterygium  may  be 
excised,  and  the  exposed  sclera  covered  by  an  epithelial 
graft  from  the  skin  or  the  mucous  membrane  of  the 
lip. 

Symblepharon  operations  usually  aim  at  covering 
with  epithelium  the  surface  exposed  when  the  eyeball  is 
dissected  free  from  its  adhesions  to  the  lid.  This  may 
be  done  by  grafts  of  skin  or  mucous  membrane,  or,  in 
some  cases,  by  sliding-flaps  of  conjunctiva,  or  by  turning 
in  a  skin-flap.  The  epithelial  grafts  may  be  spread  upon 
an  artificial  eye,  which  when  inserted  will  retain  them 
in  proper  position  until  firmly  adherent. 

Epithelial  grafts  of  mucous  membrane  may  be 
obtained  from  the  conjunctiva  of  the  rabbit,  but  will  com- 
monly be  taken  from  the  under  lip  of  the  patient.  The 
surface  having  been  prepared  for  its  reception,  the  lip  is 
grasped  by  fenestrated  forceps,  which  put  a  portion  of  its 
mucous  surface  on  the  stretch  and  turn  it  out  so  that  an 
epithelial  flap  can  be  cut  with  a  razor,  as  in  epithelial 
skin-grafting.  This  flap  is  similarly  floated  into  position, 
pressed  into  place  by  moistened  cotton  swabs,  and  allowed 
to  dry  for  a  few  minutes  before  the  lids  are  closed.  Both 
eyes  are  closed  for  the  first  day  or  two,  and  after  that 
the  operated  eye  is  closed  for  three  or  four  days.  Such 
flaps  come  to  resemble  the  conjunctiva  in  appearance, 


COMMON  OPERATIONS.  539 

while  skin-flaps  always  remain  white,  and  on  the  eyeball 
are  somewhat  disfiguring. 

Trachoma  operations  are  designed  to  expel  the 
peculiar  infiltrate  that  characterizes  the  disease.  They 
should  be  thorough,  and  done  under  general  anesthesia. 
Knapp's  roller-operation  is  preferred.  The  upper  lid 
is  everted  (see  page  58),  and  the  fold  thus  formed  is 
grasped  with  fixation-forceps,  and  turned  out  so  as  to  ex- 
pose the  retrotarsal  fold.  One  blade  of  the  roller-forceps 
(Fig.  160)  is  then  thrust  into  the  fold,  the  other  is  ap- 
plied to  the  everted  surface  of  the  lid,  the  two  are  pressed 
firmly  together,  and  as  they  are  pulled  away,  press  out 
the  gray  gelatinous  exudate.  The  rollers  are  then  ap- 


FIG.  160. — Knapp's  roller-forceps  for  trachoma. 

plied  to  a  slightly  different  portion,  and  the  movement 
repeated,  until  the  conjunctiva  is  free  from  granules  and 
the  lid-tissues  very  soft  and  flexible. 

To  clear  the  parts  near  the  lid-margins  and  commis- 
sures, one  roller  is  placed  in  the  conjunctiva,  and  the  other 
upon  the  skin-surface.  Thus  every  part  of  the  fold  of 
transition,  and  even  the  periphery  of  the  ocular  conjunc- 
tiva, can  be  brought  within  the  grasp  of  the  forceps. 
Care  should  be  taken  not  to  include  and  disturb  the  ocular 
conjunctiva  more  than  is  necessary,  and  to  see  that  the 
rollers  turn  freely,  so  as  not  to  drag  and  tear  the  con- 
junctiva. After  the  rolling  is  finished,  the  parts  are  to 
be  cleansed  with  boric  acid  solution.  The  operation  is 
followed  by  swelling  and  discoloration  of  the  lids,  which 
may  be  kept  down  by  the  use  of  ice  for  a  few  hours. 
Relief  is  marked  within  the  first  two  or  three  days,  but 
additional  treatment  must  be  used  to  complete  the  cure. 

Peritomy  may  be  done  for  pannus  when  it  continues 
after  the  lids  have  been  rendered  comparatively  smooth. 


540  PERITOMY. 

It  consists  in  the  removal  of  a  strip  of  conjunctiva  and  sub- 
conjunctival  tissue  around  the  circumference  of  the  cornea. 
The  strip  removed  should  be  4  or  5  mm.  wide,  an  in- 
cision being  made  that  distance  from  the  corneal  margin, 
and  the  tissue  thoroughly  scraped  away  down  to  the 
sclera.  Usually  the  tissue  is  removed  all  around  the 
cornea,  but  sometimes  the  removal  may  be  confined  to  a 
part  of  the  limbus  a  little  greater  than  that  through 
which  vessels  enter  the  corneal  tissue. 


OPERATIONS  ON  THE  LACRIMAL  PASSAGES. 

Syringing  of  the  passages  is  done  either  through  the 
normal  canaliculus,  after  slight  dilatation  of  the  punc- 
tum,  or  through  the  slit  canaliculus.  The  tube  to  be  in- 
troduced through  thepunctum  should  be  about  the  thickness 
of  a  No.  2  Bowman's  probe  having  an  outside  diameter 
of  little  over  ^  millimeter,  and  may  be  curved  to  90 
degrees.  The  tube  to  be  used  after  slitting  the  canaliculus 
should  be  rather  conical,  about  1.5  mm.  in  diameter  at 
the  tip,  and  enlarging  rapidly  from  this  so  as  to  fill  the 
opening  into  the  sac  whatever  its  size.  The  ordinary 
hypodermic  syringe,  or  a  dental  syringe,  can  be  used,  but 
it  is  better  to  have  one  the  barrel  of  which  holds  two 
fluid-drams.  It  must  not  leak  either  at  tube  or  piston, 
for  in  some  cases  the  obstruction  may  be  overcome  by  the 
use  of  moderate  persistent  force ;  and  it  is  safe  to  use 
thus  what  force  can  be  applied  without  causing  serious 
pain.  For  solutions  of  silver  nitrate  a  gold  tube  or  a 
glass  syringe  may  be  employed. 

Slitting  the  canaliculus  is  done  for  misplacement 
of  the  punctum  and  as  a  preliminary  to  treatment  of 
obstruction  of  the  nasal  duct.  It  is  done  with  a  knife 
having  a  probe-point,  which  is  made  to  enter  the  punc- 
tum, and  being  pushed  along  the  canaliculus,  this  point 
guides  the  knife  as  it  cuts  its  way  into  the  lacrimal 
sac.  A  finger  on  the  lid  keeps  it  tense  against  the  edge 
of  the  knife.  Great  care  should  be  taken  to  evert  the  lid 
in  the  region  of  the  canaliculus,  and  to  turn  the  edge  of 


COMMON  OPERATIONS. 


541 


the  knife  toward  the  eyeball  so  that  the  cut  shall  be  made 
into  the  conjunctiva,  and  not   in   the   lid-margin.       If 
probes  are  to  be  passed,  care  must  be  also  taken  to  make 
a  large  opening  into  the  sac  by 
pressing  with  the  point  of  the 
knife   as   it   is   withdrawn.      A 
narrow  entrance  to  the  sac  hin- 
ders the  passage  of  the  probe, 
causes    pain    and    the    risk   of 
making  a  false  passage. 

Probing  the  Nasal  Duct. 
— Lacrimal  probes  are  made  of 
silver,  or  the  larger  ones  of 
aluminum.  Bowman's  are  num- 
bered from  1  to  8,  Theobald's, 
from  1  to  16.  No.  1  is  .25  mm. 
in  diameter,  No.  16  is  4  mm. 
in  diameter.  The  smallest  are 
chiefly  useful  in  probing  the 
canaliculi.  Those  of  chief  value 
for  the  nasal  duct  are  Nos.  6  to 
13.  The  probe  should  be  given 
a  curve  approximating  that  shown 
in  Fig.  161,  and  the  ends  should 
be  bluntly  conical. 

The  canaliculus  having  been 
slit,  the  patient's  head  is  firmly 
supported,  the  lid  is  put  upon  the 
stretch,  and  the  point  of  the  probe 
carried  in  the  direction  of  the 
slit  canaliculus  until  it  is  ar- 
rested at  the  inner  wall  of  the 
lacrimal  sac  by  the  resistance 
of  the  nasal  bone.  The  probe 
is  then  turned  so  that  the  lower 
end  points  downward,  a  very  lit- 
tle forward,  and  slightly  from  the  median  line.  Thrust- 
ing it  in  this  direction,  with  a  slight  rotary  motion,  to  dis- 
engage the  point  and  find  most  exactly  the  direction  of 


[16 


FIG.  161.— Theobald's  lacrimal 
probe. 


642  PROBING   THE  NASAL  DUCT. 

the  canal,  the  chief  resistance  is  encountered  at  the  upper 
end  of  the  nasal  duct.  The  point  being  carried  through 
by  firm,  steady  pressure,  there  is  still  encountered  a  less 
resistance  from  the  grasp  of  the  stricture  on  the  sides  of 
the  probe,  until  the  point  comes  in  contact  with  the  floor 
of  the  nose,  or  sometimes  a  bony  obstruction  at  the  exit 
of  the  duct. 

The  operation  causes  pain,  which  is  only  moderated  by 
previously  injecting  the  passages  with  cocain  solution.  In 
children  and  nervous  persons  it  will  be  better  to  use  a 
general  anesthetic.  It  is  best  to  begin  with  about  a  No. 
6  probe,  and  in  general  to  pass  the  largest  that  can  be 
passed  without  excessive  force.  The  probe  should  remain 
in  position  twenty  to  forty  minutes.  It  should  be  intro- 
duced every  second  day ;  and  when  the  largest  probe, 
usually  No.  11  to  No.  13,  has  been  used,  the  intervals  may 
be  lengthened. 

Cutting  a  I^acritnal  Stricture. — After  the  passage 
of  a  No.  6  probe,  the  Thomas  stricturotome  (Fig.  162) 


FIG.  162.— Thomas  stricturotome. 


is  introduced  in  the  same  manner  as  a  lacrimal  probe ; 
as  it  is  withdrawn  the  cutting  edge  is  pressed  firmly 
against  the  stricture,  incising  it.  When  the  stricture  has 
thus  been  divided,  the  instrument  may  be  pushed  down, 
with  the  blade  turned  in  another  direction,  the  shank  being 
flexible  to  allow  of  this  turning,  and  a  second  cut  made. 
After  the  stricture  is  freely  incised,  a  style  made  of  lead 
wire  3  mm.  in  diameter,  carefully  fitted  to  the  passages, 
and  retained  by  a  bent  upper  end,  that  lies  in  the  slit 
canaliculus,  is  introduced.  This  is  to  be  removed,  and 
the  passages  cleansed,  at  first  every  day  or  two,  then  at 
longer  intervals  until  at  the  end  of  a  few  weeks  the  style 
can  be  omitted. 

Extirpation  of  the  lacrimal  sac  is  done  by  the 


COMMON  OPERATIONS.  543 

method  of  Prince,  thus  :  Introduce  a  small  strabismus- 
hook  into  the  sac,  and  press  forward  the  anterior  wall 
with  its  point.  Incise  the  tissues  over  this  point,  enlarge 
the  incision  upward  and  downward  to  the  limits  of  the 
sac,  and  open  all  sinuses  freely.  Apply  thoroughly  to  all 
the  surfaces  thus  exposed  a  saturated  solution  of  mono- 
chloracetic  acid,  and  keep  the  cavity  packed  with  iodoform 
until  the  healing  is  complete. 

OPERATIONS  ON  THE  EYE-MUSCLES. 

Tenotomy  is  done  to  lessen  the  influence  of  the  ten- 
otomized  muscle  on  the  position  of  the  eyeball,  as  upon 
the  internal  rectus  for  convergent  squint.  With  fixation- 
forceps  the  conjunctiva  and  subconjunctival  tissue  are 
raised  in  a  fold  parallel  with  the  corneal  margin,  over  the 
insertion  of  the  tendon  to  be  divided,  5  mm.  back  from 
the  cornea  for  the  internal  rectus,  7  mm.  for  the  external. 
This  fold  is  then  divided  horizontally  by  snips  of  the 


FIG.  163.— Strabismus-hook. 


scissors  cutting  down  to  the  solera.  A  strabismus-hook 
(Fig.  163)  is  then  introduced,  with  its  point  pressed  firmly 
against  the  sclera  below  and  behind  the  insertion  of  the 
tendon,  and  passed  upward  until  it  includes  the  upper 


FIG.  164. — Strabismus-scissors. 


margin  of  the  tendon.  It  is  then  drawn  upon  sufficiently 
to  put  the  tendon  slightly  on  the  stretch.  Blunt-pointed 
strabismus-scissors  (Fig.  164)  are  then  passed  with  one 
blade  in  contact  with  the  hook,  and  the  other  beneath  the 


544  TENOTOMY. 

conjunctiva,  but  in  front  of  the  tendon,  and  by  successive 
snips  the  included  part  of  the  tendon  is  divided.  The 
hook  is  then  turned  with  the  point  down,  so  as  to  make 
sure  to  include  the  lower  part  of  the  tendon,  and  this  is 
fully  divided.  Sometimes  side  slips  of  tissue  connecting 
the  tendon  with  the  sclera  must  also  be  fished  up  with  the 
hook  and  severed.  When  all  limiting  fibers  have  thus 
been  divided,  the  hook  can  be  readily  drawn  forward  to 
the  corneal  margin. 

Partial  tenotomy  differs  from  complete  in  leaving  a 
thin  strand  of  tissue  standing  at  each  margin  of  the  ten- 
don, which  can  be  stretched  with  the  hook  to  the  desired 
state  of  relaxation. 

The  possible  accidents  that  may  complicate  tenotomy 
are :  failure  at  first  to  get  the  hook  under  the  tendon ; 
excessive  hemorrhage  necessitating  a  free  opening  in  the 
conjunctiva  for  its  removal,  or  even  the  suspension  of  the 
operation  and  the  use  of  ice  or  pressure ;  and  perforation 
of  the  sclera  by  an  awkward  snip,  in  an  unruly  patient. 

After  the  operation  the  eye  should  be  cleansed  and 
closed  for  a  few  hours,  and  then  left  open.  The  change 
of  direction  of  the  eye  by  a  single  full  tenotomy  varies 
greatly,  but  in  a  majority  of  cases  it  is  between  10  degrees 
and  15  degrees. 

Advancement  of  one  of  the  ocular  muscles  is  done 
to  increase  its  influence  upon  the  position  of  the  eyeball. 
Thus,  in  divergent  squint,  the  internal  rectus  muscle 
should  be  advanced  to  turn  the  eye  in.  When  a  great 
rotation  of  the  eye  is  desired,  advancement  of  one  muscle 
is  combined  writh  tenotomy  of  its  antagonist.  The  effect 
may  also  be  increased  by  including  in  the  sutures  the 
capsule  of  Tenon  and  overlying  tissue. 

To  advance  the  tendon  alone,  an  incision  10  mm.  long 
is  made  parallel  to  the  line  of  insertion  of  the  tendon  and 
midway  between  that  line  and  the  corneal  margin.  The 
conjunctiva  is  then  undermined  to  the  corneal  margin 
and  back  as  far  as  the  suture  is  to  be  introduced,  and  the 
tendon  is  isolated  that  far  back.  A  ligature  of  black  silk, 
with  a  fine  needle  at  each  end,  is  fixed  to  the  globe,  by 


COMMON  OPERATIONS.  545 

passing  one  of  the  needles  beneath  the  superficial  layers 
of  the  solera  parallel  to  the  corneal  margin,  and  quite  close 
to  it,  so  that  the  ligature  includes  2  or  3  mm.  width  of  firm 
scleral  tissue.  The  tendon  is  then  raised  on  a  strabismus- 
hook.  One  needle  is  carried  under  the  lower  edge  of  the 
tendon  and  made  to  pierce  it  from  beneath,  sufficiently 
far  back  from  its  insertion ;  the  other  needle  is  similarly 
passed  the  same  distance  back  beneath  the  upper  edge,  so 
that  the  two  ends  of  the  ligature  shall  include  between 
them  about  the  middle  third  of  the  tendon.  The  two 
loops  are  now  drawn  safely  out  of  the  way,  and  the  ten- 
don divided  at  its  insertion.  If  the  end  of  the  tendon 
included  by  the  ligature  is  over  3  or  4  mm.  in  length,  the 
excess  should  be  cut  off.  The  eye  is  then  drawn  into 
proper  position  and  the  stitch  tied.  The  eye  is  kept 
closed  for  a  few  hours,  and  then  regularly  cleansed.  The 
stitch  is  removed  in  eight  or  ten  days. 

When  the  overlying  tissues  are  to  be  included  they  are 
not  dissected  up  from  the  tendon,  and  additional  stitches 
may  be  placed  above  and  below  the  one  described,  ex- 
tending close  to  the  upper  and  lower  margins  of  the 
cornea. 

OPERATIONS  ON  THE  CORNEA. 

Removal  of  Foreign  Bodies. — A  local  anesthetic 
should  be  used  and  the  patient  convinced  by  touching  of 
the  eye  that  the  operation  will  not  hurt.  He  is  then 
directed  to  keep  both  eyes  open  and  fixed  in  a  certain 
direction,  to  bring  the  eye  into  favorable  position.  The 
spud  shown  in  Fig.  165  is  then  placed  alongside  the 
foreign  body  and  pushed  steadily  between  it  and  the  cor- 
neal tissue  until  the  foreign  body  is  loosened  and  dis- 
placed, and  can  be  wiped  away.  Sudden  dabbing  and 
miscellaneous  scraping  while  the  patient  is  rolling  the  eye 
about  are  to  be  avoided.  Small  foreign  bodies  require  the 
use  of  a  magnifier  (see  page  69),  and  in  any  case  the  cor- 
neal injury  should  be  examined  with  a  magnifying  lens  to 
see  that  no  particles  of  foreign  substance  remain.  Any 

35 


546  FOREIGN  BODY  IN  CORNEA. 

softened  or  probably  infected  tissue  adjacent  should  also 
be  scraped  away. 

Curetting  of  the  cornea  is  practised  for  infected 
corneal  ulcers.  After  instilling  a  local  anesthetic,  all 
softened  tissue  in  the  ulcer  is  scraped  away  with  a  corneal 
spud  or  spatula.  The  tissue  adjoining  the  ulcer  is  also 


FIG.  165.— Spud  for  removing  foreign  bodies  from  the  cornea. 

scraped  from  the  sound  tissue  toward  the  center  of  the 
ulcer,  to  press  out  whatever  infected  exudate  may  be 
present  in  it.  This  scraping  should  be  repeated  so  often 
as  the  slightest  extension  of  corneal  infiltration  can  be 
detected. 

Paracentesis,  tapping  of  the  cornea,  is  resorted  to  for 
hypopyon,  or  to  relieve  intra-ocular  pressure,  as  when  a 
corneal  ulcer  is  liable  to  perforate,  or  a  swollen  lens  is 
causing  trouble.  It  is  done  under  local  anesthesia 
through  the  lower  margin  of  the  cornea.  A  paracentesis- 
needle  (Fig.  166),  with  a  thick  shoulder  to  prevent  it 
from  entering  too  deeply,  a  broad  needle,  or  the  point  of 
a  Graefe  knife  may  be  used.  The  incision,  is  made 
parallel  to  the  corneal  margin.  Care  must  be  taken  not 


FIG.  166.— Paracentesis-needle. 


to  wound  the  iris  or  lens.  The  incision  may  be  reopened 
by  introducing  a  probe  once  daily  so  long  as  is  necessary. 
Incision  Through  Corneal  Ulcer  (Racmisch  Opera- 
tion).— When  an  infected  or  sloughing  ulcer  of  the  cornea 
is  extending  and  likely  to  perforate,  this  operation  is 
done  to  prevent  prolapse  of  the  iris,  drain  the  involved 
tissue,  and  to  check  the  extension  of  the  infection.  A 
Graefe  knife  is  entered  in  the  sound  tissue  on  one  side  of 
the  ulcer  with  its  back  toward  the  iris,  carried  through 
the  anterior  chamber  behind  the  ulcer,  the  point  brought 


COMMON  OPERATIONS.  547 

out  through  the  sound  tissue  on  the  other  side,  and  the 
knife  made  to  cut  its  way  out.  This  makes  an  incision 
through  the  whole  thickness  of  the  cornea,  across  the 
whole  width  of  the  ulcer,  which  may  subsequently  be 
kept  open  by  probing. 

The  actual  cautery  is  applied  to  the  cornea  to 
destroy  powder  grains,  to  check  the  progress  of  an  in- 
fected ulcer,  or  to  alter  a  chronic  ulcerative  process.  A 
platinum  needle  or  a  fragment  of  a  steel  knitting-needle 
the  size  of  a  No.  6  lacrimal  probe  may  be  employed. 
The  eye  being  placed  under  local  anesthesia,  the  needle, 
grasped  in  an  ordinary  needle-holder,  is  held  in  the  flame 
of  an  alcohol  lamp  until  its  end  is  white  hot,  and  then  is 
quickly  touched  to  the  point  to  be  cauterized.  This  may 
be  repeated  several  times  until  the  necessary  extent  of 
tissue  has  been  cauterized.  The  operation  is  attended 
with  little  pain,  unless  the  hot  needle  is  held  too  long 
close  to  the  eye.  Cauterization  should  be  thorough, 
destroying  all  infected  tissue,  the  extent  of  which  may  be 
previously  made  more  evident  by  use  of  fluorescin. 

The  gal vano- cautery  may  be  used  for  the  same 
purpose  as  the  above,  or  to  open  a  corneal  abscess  or  the 
anterior  chamber,  or  for  conical  cornea.  On  account 
of  its  greater  manageability  and  rapidity  of  action  it  is 
preferable  wrhere  many  powder-grains  are  to  be  destroyed. 
The  small  platinum  tip  is  attached  to  a  handle  in  which 
the  circuit  can  be  readily  made  and  broken.  The  con- 
ductors should  be  light,  and  so  supported  as  not  to  drag 
on  the  handle  or  interfere  with  the  steadiness  and  accu- 
racy of  the  operator's  touch  with  the  cautery  point.  The 
tip  should  be  used  at  a  white  heat  so  as  to  do  its  work  in 
the  shortest  possible  time,  before  neighboring  tissues  can 
be  injured  by  heat.  The  necessary  current  may  be  ob- 
tained by  an  adapter  from  the  incandescent-light  current, 
from  a  storage  battery,  or  from  three  or  four  good  cautery- 
cells.  The  circuit  is  made  as  the  cautery  tip  is  brought 
near  the  point  to  \vhich  it  is  to  be  applied,  and  broken 
the  instant  the  application  ceases.  It  is  better  to  make 
a  number  of  short  applications  than  to  attempt  to  burn 


548  APPLICATION  OF  CAUTERY. 

much  tissue  at  a  single  contact.  For  conical  cornea  the 
anterior  chamber  should  be  penetrated. 

Tattooing  the  cornea  is  employed  to  overcome  the 
unsightly  appearance  of  a  corneal  leucoma.  The  eye 
should  previously  be  free  from  irritation,  and  the  tissue 
to  be  colored  must  be  but  slightly  vascular.  India  ink 
is  rubbed  in  distilled  water  to  a  thick  paste,  spread  on  the 
part  of  the  cornea  to  be  colored ;  and  picked  in,  either 
with  a  small  flat  needle  like  the  Bowman  needles,  or  with 
a  bundle  of  fine  cambric  needles  in  a  special  handle,  or 
bound  together  so  that  when  held  obliquely  their  points 
will  all  penetrate  the  cornea  equally.  The  punctures 
should  be  as  oblique  as  possible  to  the  corneal  surface. 
The  operation  may  require  to  be  repeated  until  the  center 
is  colored  black  like  the  pupil,  and  the  other  parts  gray 
to  represent  the  iris.  The  color  may  slowly  diminish  by 
diffusion,  and  requires  renewal  to  keep  a  black  center. 
If  the  operation  is  aseptic,  but  slight  irritation  follows. 

Fuchs  removes  a  circle  of  the  anterior  corneal  surface, 
tattoos  the  underlying  tissue,  and  replaces  the  circle  as  a 
temporary  covering. 

Excision  of  anterior  staphyloma  (abscission  or 
keratectomy)  may  be  resorted  to,  when  nothing  can  be 
hoped  from  iridectomy.  With  a  Graefe  or  Beer's  knife 
the  staphyloma  is  transfixed  from  side  to  side,  the  point 
of  entrance  and  exit  lying  fairly  behind  the  staphyloma. 
The  edge  of  the  knife  being  directed  toward  the  upper  or 
lower  margin,  it  is  made  to  cut  out,  separating  one-half 
the  base  of  the  staphyloma ;  the  other  half  is  then  sev- 
ered with  slightly  curved  scissors.  Any  pieces  of  thick 
hard  tissue  in  the  margins  of  the  wound,  or  tags  of  loose 
hanging  tissue,  should  be  trimmed  away.  The  two  sides 
of  the  wound  may  be  brought  together  with  three  or 
more  fine  sutures,  the  eye  dusted  with  iodoform,  cleansed 
twice  a  day  and  kept  closed  under  a  dressing  until  the 
sutures  are  removed  in  from  five  to  ten  days. 


COMMON  OPERATIONS.  549 

OPERATIONS  ON  THE  SCLERA. 

Anterior  sclerotomy  is  done  for  glaucoma.  A  nar- 
row Graefe  knife  entered  1  mm.  behind  the  upper  outer 
part  of  the  sclerocorneal  junction  is  brought  out  at  a  cor- 
responding point  of  the  nasal  margin  of  the  cornea.  By 
a  slow  sawing  movement  the  knife  is  made  to  pass  be- 
tween the  iris  and  cornea,  making  a  scleral  incision  until 
the  bridge  of  uncut  tissue  is  reduced  to  about  3  mm., 
when  the  knife  is  withdrawn.  If  the  iris  prolapses  into 
either  side  of  the  wound,  as  shown  by  the  pupil  becoming 
oval,  it  must  be  drawn  out  and  cut  off. 

Posterior  sclerotomy  is  done  for  glaucoma,  detach- 
ment of  the  retina,  or  for  the  extraction  of  a  foreign  body 
or  a  cysticercus.  The  point  of  election  is  near  the  equator 
of  the  eyeball  above  or  below  the  external  rectus.  But  it 
may  be  needful  to  place  the  incision  under  the  greatest 
detachment  of  the  retina,  or  most  convenient  to  a  foreign 
body.  The  incision  is  made  radially  in  the  direction  of 
a  great  circle  passing  through  the  anterior  and  posterior 
poles  of  the  eye,  with  a  narrow  knife  or  broad  needle. 
By  slightly  displacing  the  conjunctiva  before  inserting 
the  knife,  the  scleral  opening  is  made  subconjunctival. 
The  knife  may  be  turned  in  the  wound  before  withdraw- 
ing it,  or  a  spatula  may  be  substituted  for  it,  to  allow  the 
escape  of  the  contents  from  the  interior  of  the  globe. 
Unless  the  incision  is  very  extensive,  it  requires  no 
suture. 

OPERATIONS  ON  THE  IRIS. 

Iridectotny. — Removal  of  a  piece  of  the  iris  is  an 
operation  that  presents  important  variations  according  to 
the  purpose  for  which  it  is  done.  It  is  done  as  &  prelimi- 
nary to  the  extraction  of  cataract,  when  the  pupil  is 
excessively  small,  or  its  margin  bound  down  with  adhe- 
sions, or  there  are  special  risks  for  a  cataract-extraction. 
Experience  has  shown  that  the  risks  are  slightly  less 
when  the  iridectomy  is  done  as  a  preliminary  operation 
than  when  it  is  done  at  the  time  of  extraction. 

The  eye  is  placed  under  local  anesthesia,  the  lids  re- 


550  IRIDECTOMY. 

tracted  with  a  speculum,  and  the  globe  steadied  with  the 
fixation-forceps.  The  point  of  a  bent  keratome  (Fig.  167) 
is  entered  at  the  upper  margin  of  the  cornea  and  pushed 
steadily  forward,  with  the  plane  of  the  blade  parallel  to 
the  plane  of  the  iris,  until  the  corneal  incision  is  suffi- 
ciently long,  6  to  8  mm.  Then  the  knife  is  withdrawn 


FIG.  167.— Bent  keratome. 

without  touching  the  iris  or  lens,  or  scraping  the  cornea  with 
the  point.  The  iris-forceps  (Fig.  168)  are  introduced  into 
the  corneal  incision,  opened  slightly,  made  to  seize  the 
iris  near  its  pupillary  margin,  and  withdrawn,  dragging 
this  part  of  the  iris  with  them.  The  part  of  the  iris 
drawn  out  is  then  cut  off  with  one  snip  of  the  scissors. 
The  iris-stump  is  usually  promptly  retracted.  If  caught 
in  the  angles  of  the  wound,  it  must  be  carefully  freed  and 
returned  within  the  anterior  chamber,  either  by  making 
the  wound  gape  by  pressure  on  the  sclera,  or  by  stroking 
with  a  spatula  from  the  angles  toward  the  center  of  the 
wound.  Blood  remaining  within  the  anterior  chamber 
need  cause  no  alarm,  it  will  be  quickly  absorbed.  The 


FIG.  168.— Curved  iris-forceps. 

eye  is  then  to  be  closed  with  a  light  bandage  for  a  day  or 
two  until  the  corneal  incision  has  closed.  A  mydriatic 
should  be  used  until  the  eye  is  free  from  redness. 

The  anesthesia  of  the  iris  produced  by  cocain  or  holo- 
cain  is  often  imperfect.  It  may  be  improved  by  placing 
a  drop  of  the  anesthetic  solution  upon  the  corneal  incision 


COMMON  OPERATIONS.  551 

before  attacking  the  iris.  But  the  patient  should  be 
warned  that  the  cut  may  hurt  a  little,  so  that  he  may 
make  a  special  effort  to  avoid  any  sudden  movement. 
The  symmetry  of  the  iridectomy  depends  on  seizing  the 
iris  opposite  the  middle  of  the  cornea!  incision,  and  hold- 
ing it  opposite  the  center  while  being  cut.  The  size  of 
the  iridectomy  will  depend  on  the  amount  of  iris  drawn 
into  the  scissors ;  but  when  the  iris  returns  to  its  position 
it  will  generally  appear  larger  than  might  have  been  ex- 
pected. When  the  iris-margin  is  firmly  bound  down  to 


FIG.  169.— Blunt  iris-hook. 


the  lens-capsule  it  is  more  readily  freed  and  brought  out 
by  the  blunt  iris-hook  (Fig.  169)  than  with  the  forceps. 

Optical  iridectomy  is  required  when  the  natural  pupil 
is  obstructed  by  opacity  of  the  cornea,  partial  cataract  or 
deposit  on  the  lens-capsule.  If  the  eye  already  possesses 
some  vision,  and  especially  if  the  other  eye  has  good  vision, 
the  result  of  the  operation  is  apt  to  be  disappointing. 
The  refraction  of  light  is  always  irregular  at  the  peri- 
phery of  the  cornea  and  lens,  and  a  portion  of  the  cornea 
that  looks  clear  with  iris  behind  it  may  be  found  quite 
hazy  when  seen  against  an  artificial  pupil.  But  if  the 
patient  was  previously  entirely  blind,  the  restoration  of 
some  sight  is  very  highly  appreciated. 

An  optical  iridectomy  must  be  located  so  as  to  give  the 
best  vision,  where  the  media  are  clearest,  and  where  it 
will  not  be  covered  by  the  margin  of  the  lid.  The  best 
effect  will  be  obtained  by  making  the  opening  in  the  iris 
as  small  as  possible,  thus  reducing  the  diffusion  of  light 
due  to  imperfect  focussing.  If  the  iris  is  universally 
adherent  to  the  lens-capsule,  it  will  only  be  possible  to  get 
a  clear  artificial  pupil  by  extracting  the  lens. 

Iridectomy  for  glaucoma  is  best  done  through  a 
scleral  incision  made  about  1  rnm.  outside  the  margin 
of  the  cornea.  At  least  one-fifth  of  the  iris  should  be 


552  IRIDECTOMY. 

removed,  entirely  up  to  the  ciliary  margin.  If  the  eye  is 
inflamed  this  should  be  done  under  general  anesthesia. 
On  account  of  the  shallovvness  of  the  anterior  chamber 
and  the  length  of  incision  required,  the  corneal  incision  is 
made  with  a  narrow  knife,  used  as  in  cataract-extraction, 
to  make  a  puncture  and  counter-puncture  and  then  to 
divide  the  intervening  bridge  of  tissue.  The  iris  being 
drawn  well  out,  one  blade  of  the  iris-scissors  is  introduced 
through  the  pupil  behind  the  iris,  and,  the  iris  being 
dragged  towards  one  side  of  the  corneal  incision,  a  radial 
cut  is  made  in  the  iris  at  the  other  side.  The  iris  is  then 
torn  loose  from  its  ciliary  insertion,  and  at  the  other  angle 
of  the  corneal  incision  a  second  radial  cut  completes  the 
iridectomy. 


ABC 

FIG.  170.— Various  forms  of  iridectomy :  A,  Optical  iridectomy  forocclusion 
of  the  pupil.  B,  Small  iridectomy  preliminary  to  extraction  of  the  lens.  C, 
Iridectomy  for  glaucoma. 

The  typical  colobomas  obtained  in  the  different  forms 
of  iridectomy  are  shown  in  Fig.  170. 

Iridotomy  is  incision  of  the  stretched  iris-fibers,  to 
make  an  artificial  pupil  when  the  natural  pupil  has  been 
closed  by  inflammation,  following  an  operation  or  injury 
which  has  removed  the  crystalline  lens.  It  may  be  a 
simple  cut  made  with  a  narrow  knife  perpendicular  to  the 
iris-fibers,  or  two  cuts  forming  a  V  made  with  Wecker's 
forceps-scissors,  introduced  through  a  corneal  incision  and 
the  sharp  blade  thrust  through  the  iris.  A  similar  opera- 
tion including  both  iris  and  lens-capsule  is  called  irido- 
cystectomy. 

Corelysis,  or  breaking  loose  of  iritic  adhesions,  may  be 
done  with  a  carefully  rounded  blunt  hook  introduced 
through  a  small  corneal  incision  and  passed  behind  the 
margin  of  the  pupil.  Great  care  should  be  taken  not  to 
injure  the  lens-capsule. 


COMMON  OPERATIONS,  553 

Iridencleisis  is  dragging  the  iris  into  a  small  corneal 
incision  and  leaving  it  fast  there,  to  give  a  small  and 
favorably  situated  pupil,  in  cases  of  corneal  opacity.  In 
iridodesis  (iridesis)  the  small  prolapse  of  the  iris  obtained 
for  the  same  purpose  is  tied  with  a  delicate  silk  thread. 

OPERATIONS  UPON  THE  LENS  AND  ITS  CAPSULE. 

The  cataract-knife  is  usually  the  broad  knife  of  Beer 
(Fig.  171),  Sichel  and  Richter,  or  the  narrow  knife  of 


FIG.  171.— Beer's  cataract-knife. 


Graefe  (Fig.  172).     The  author  prefers  the  knife  shown 
in  Fig.  173,  3.5  or  4  mm.  wide  at  its  widest  part. 
Simple  Extraction. — The  lids,  conjunctiva,  and  lid- 


FIG.  172.— Graefe's  cataract-knife. 


margins  having  been  very  thoroughly  cleansed,  local  anes- 
thesia is  produced  by  not  more  than  three  instillations  of 
cocain,  or  holocain  solution,  at  intervals  of  five  minutes. 


FIG.  173.— The  author's  cataract-knife. 


The  patient  lies  on  a  bed  or  table.  The  operator  stands  or 
sits  at  his  head ;  or,  if  not  ambidextrous,  at  the  patient's 
left  side  for  his  left  eye.  The  lids  being  held  by  a  spec- 
ulum, the  eye  is  fixed  by  grasping  with  forceps  the 
tissue  at  the  lower  nasal  margin  of  the  cornea.  The 
patient  is  also  strongly  urged  to  assist  fixation  by  keep- 
ing his  other  eye  steadily  directed  rather  downward 
throughout  the  operation.  The  cataract-knife  is  en- 


554  CA  TAR  A  CT-EXTRA  CTION. 

tered  just  in  the  margin  of  the  clear  cornea  and  1  or  2 
mm.  above  the  temporal  end  of  the  horizontal  diameter, 
starting  at  the  position  shown  by  the  solid  lines  in  Fig. 
174,  with  its  cutting  edge  upwards  and  its  plane  parallel 
to  the  plane  of  the  iris.  The  knife  is  then  thrust  hori- 
zontally forward,  the  point  emerging  through  the  counter- 
puncture  symmetrically  placed  at  the  nasal  side  of  the 
cornea.  The  knife  is  pushed  on  until  it  reaches  the 
position  indicated  by  the  broken  lines,  and  is  then  with- 
drawn with  an  upward  pressure  sufficient  to  divide  the 
remaining  bridge  of  tissue. 

The  eye  is  allowed  to  rest  an  instant,  before  proceeding 
to  open  the  capsule.  The  knife  is  cleansed  with  boric  acid 
solution,  and  its  back  introduced  in  the  corneal  incision 
until  it  is  almost  in  the  position  shown  by  the  broken  lines, 
(Fig.  174).  It  is  then  withdrawn  until  its  point  lies  in 


FIG.  174.— Cataract-incision.  The  solid  lines  show  position  of  knife  com- 
mencing the  incision.  The  broken  line  shows  the  position  of  greatest  forward 
thrust.  The  remaining  bridge  of  tissue,  shown  by  the  dotted  curve,  is  to  be 
divided  as  the  knife  is  withdrawn. 

the  upper  temporal  margin  of  the  pupil  where  it  is  made 
to  enter  the  lens-capsule.  The  knife  is  now  thrust  forward 
so  that  its  cutting  edge  makes  an  incision  in  the  capsule 
at  the  upper  part  of  the  pupil,  and  the  edge  comes  in  con- 
tact with  the  upper  nasal  margin  of  the  pupil.  The  knife 
is  then  withdrawn,  and  the  eye  released  from  the  fixation- 
forceps. 

Most  operators  open  the  capsule  with  a  special  instru- 
ment, the  cystotome,  shown  in  Fig.  175.  The  point  is 
introduced  sidewise,  then  turned  toward  the  capsule,  and 
made  to  open  it  by  one  or  more  scratches. 

The  delivery  of  the  lens  is  accomplished  by  placing 
the  back  of  the  lens-spoon  against  the  lower  margin  of 
the  cornea,  and  pressing  directly  backward.  This  tilts 
the  lower  margin  of  the  lens  backward,  and  causes  the 


COMMON  OPERATIONS.  555 

upper  margin  to  be  pushed  forward,  where  it  dilates 
the  pupil  and  enters  the  corneal  wound.  Slight  counter- 
pressure  may  be  made  on  the  sclera  just  above  the  cor- 
nea with  a  spatula,  which  may  also  be  made  to  retract 
the  center  of  the  upper  lip  of  the  corneal  incision,  if 
necessary  to  facilitate  escape  of  the  lens.  The  pressure 
is  steadily  continued,  so  graduated  as  to  keep  the  lens 


FIG.  175.— Cystotome. 

advancing ;  but  giving  time  for  the  sphincter  of  the  pupil 
to  stretch,  and  the  lens  to  change  shape  under  pressure. 
The  pressure  must  not  be  intermitted  until  the  widest 
part  of  the  lens-nucleus  has  emerged  from  the  corneal 
wound.  Then  the  pressure  may  be  slightly  but  not  en- 
tirely relaxed  while  an  assistant  removes  the  lens-nucleus ; 
and  the  surgeon  carefully  inspects  the  pupil.  If  it  is  be- 
lieved that  some  cortex  remains  in  the  lens-capsule,  the 
pressure  is  renewed  and  the  lens-spoon  is  slid  up  after  the 
cortical  masses ;  or  the  lower  lid-margin  is  substituted  for 
the  lens-spoon  until  the  fragments  of  cortex  are  pressed 
out. 

The  iris  is  then  to  be  returned  to  its  normal  position 
by  making  the  corneal  incision  gape  by  slight  manipula- 
tion of  the  globe,  or  by  lightly  stroking  the  iris  out  of  the 
angles  of  the  corneal  incision.  When  the  pupil  becomes 
circular  and  central,  the  eye  is  to  be  cleansed  with  boric 
acid  solution  and  dressed. 

Errors  and  Complications. — The  knife  in  the  ante- 
terior  chamber  appears  more  superficial  than  it  really 
is,  and  therefore  the  point  is  liable  to  emerge  too  far 
back.  If  this  is  discovered  before  the  counter-puncture 
is  complete,  or  while  still  quite  small,  it  may  be  rectified 
by  slight  withdrawal  of  the  knife  and  change  of  its  direc- 
tion. If  the  iris  falls  in  front  of  the  knife  it  may  often  be 
gotten  off  by  slightly  lifting  the  cutting  edge  and  then 
thrusting  quickly  forward.  If  the  knife-edge  cannot  be 


556  COMPLICATIONS  OF  EXTRACTION. 

thus  freed,  the  iris  must  be  cut,  and  the  iridectomy  sub- 
sequently made  regular ;  or  the  knife  must  be  withdrawn 
and  the  operation  postponed. 

If  the  corneal  section  is  too  short,  it  should  be  length- 
ened with  scissors  before  attempting  to  deliver  the  lens, 
taking  care  that  the  scissors  only  begin  to  cut  at  the  end 
of  the  incision,  and  not  into  one  of  the  lips  of  the  wound. 
To  attempt  to  deliver  the  lens  through  too  small  a  corneal 
incision  is  the  worst  error  one  is  likely  to  commit.  Should 
the  vitreous  prolapse,  the  nucleus  of  the  lens  should  be 
quickly  delivered  with  a  lens-spoon  or  wire  loop ;  and  the 
eye  cleansed  and  dressed  without  much  manipulation  to 
expel  cortex.  When  much  cortex  remains,  the  best  way 
to  extract  it  is  with  a  fine  stream  of  boric  acid  solution, 
or  normal  salt  solution,  from  a  special  syringe  or  irrigator. 
Lippincott's  is  about  the  best.  This  should  be  done  if 
the  lens-matter  lies  in  the  anterior  chamber.  But  if  it  is 
adherent  within  the  capsule  it  will  be  safest  to  leave  it  to 
absorption  or  a  secondary  operation,  having  warned  the 
patient  that  vision  will  be  poor  until  its  removal  is  com- 
plete. 

Hemorrhage  from  the  depth  of  the  eye  usually  destroys 
it.  It  is  to  be  checked  by  at  once  raising  the  patient  into 
the  sitting  posture,  with  the  legs  dependent,  and  applying 
ice  to  the  eye. 

Iris-prolapse. — When  the  iris  does  not  return  to  the 
anterior  chamber,  or  tends  to  prolapse  when  pushed  back, 
or  the  pupil  will  not  remain  round  and  central,  the  iris 
should  be  drawn  out  with  an  iris-hook  and  an  iridectomy 
done  to  prevent  future  prolapse.  When  the  iris  prolapses 
subsequently,  if  not  promptly  reduced,  it  may  be  cut  off, 
best  under  a  general  anesthetic.  If  the  prolapse  is  let 
alone  and  the  eye  kept  under  a  mydriatic,  the  healing 
will  be  slow  (five  to  eight  weeks),  but  the  ultimate  result 
will  be  quite  as  good  as  after  iridectomy. 

After-treatment. — Both  eyes  are  to  be  covered  with 
light  dressings,  which  are  removed  by  the  evening  of  the 
next  day,  and  the  edges  of  the  lids  carefully  cleansed  to 
prevent  any  irritation  that  would  provoke  slight  move- 


COMMON  OPERATIONS.  557 

ments.  This  cleansing  is  repeated  daily.  The  fourth  or 
fifth  day  the  unoperated  eye  is  usually  left  uncovered ; 
the  dressing  being  renewed  on  the  operated  eye  until  the 
end  of  a  week.  When  the  corneal  wound  has  been  en- 
tirely closed  and  the  anterior  chamber  re-established  for 
a  day  or  two,  a  mydriatic  may  be  instilled. 

Delayed  union  of  the  corneal  wound  sometimes  occurs, 
generally  attended  by  deficient  hyperemia  of  the  eyeball. 
Union  may  promptly  follow  the  discontinuance  of  the 
dressing. 

Extraction  with  iridectomy  resembles  the  opera- 
tion above  described,  except  that  an  iridectomy,  as  de- 
scribed on  page  549,  is  done  immediately  after  the  corneal 
section ;  and  the  corneal  section  may  be  a  little  shorter. 
The  operation  is  free  from  danger  of  prolapse  of  the  iris, 
but  incarceration  of  the  iris  in  the  angles  of  the  wound 
is  very  liable  to  occur.  It  is  more  liable  to  be  compli- 
cated by  vitreous  prolapse. 

linear  extraction  is  done  for  cataracts  destitute  of 
large  firm  muclei.  An  incision,  6  to  10  mm.  long,  is 
made  in  the  clear  cornea,  with  a  keratome  or  a  cataract- 
knife.  The  capsule  is  opened  with  the  point  of  the  knife 
and  the  soft  lens-substance  squeezed  out. 

Suction- operation  for  fluid  cataracts :  the  needle 
of  a  syringe  or  suction-curette  is  introduced  through  a 
small  incision  in  the  cornea  and  capsule,  and  the  lens- 
substance  sucked  out. 

Extraction  within  the  capsule  is  sometimes  done. 
It  is  only  suitable  for  cases  in  which  the  suspensory  liga- 
ment of  the  lens  has  undergone  atrophy. 

Scoop -extraction  is  performed  by  passing  the  wire 
loop  (Fig.  176),  or  the  lens-spoon  behind  the  lens  and 
coaxing  it  out,  when  pressure  cannot  be  made  on  the 
globe,  as  when  there  is  prolapse  of  the  vitreous. 

Wensel's  extraction  may  be  done  when  the  iris  is 
universally  adherent  to  the  lens.  The  knife  is  made  to 
cut  cornea,  iris  and  capsule  at  one  thrust ;  and  after  expul- 
sion of  the  lens,  enough  iris  and  capsule  are  removed  to 
give  a  clear  pupil. 


558  CATARACT  OPERATIONS. 

Discission  is  done  to  secure  the  absorption  of  soft 
cataract,  or  to  render  transparent  lens-substance  opaque 
and  facilitate  its  removal  by  extraction.  It  usually  re- 
quires repetition,  in  some  cases  many  times,  before  com- 
plete absorption  is  secured.  A  knife-needle  is  the  only 
essential  instrument.  It  may  be  either  straight  or  curved. 
Its  cutting  edge  should  be  3  or  4  mm.  long.  It  must 
have  a  round  shank  of  such  thickness  that  it  will  just  fill 
the  incision  made  by  the  blade.  The  eye  is  fixed  and  the 
lids  held  apart  with  the  fingers ;  or  speculum  and  fixation- 


FIG.  176.— Wire  loop  for  extraction  of  lens. 

forceps  can  be  used.  The  eye  should  be  under  strong 
oblique  illumination ;  and  the  binocular  magnifier  (Fig. 
21),  is  of  great  assistance.  The  pupil  is  fully  dilated 
with  a  mydriatic,  and  a  local  anesthetic  applied. 

The  knife-needle  is  introduced  half-way  between  the 
center  and  the  margin  of  the  cornea,  and  a  cut  made  in 
the  lens-capsule.  In  a  first  discission  for  absorption, 
there  should  be  a  single  cut  in  the  capsule  about  3  mm. 
long,  although  the  knife  may  be  turned  and  moved 
in  the  lens-substance  as  freely  as  possible  without  enlarg- 
ing the  incision.  In  later  operations,  when  the  lens  has 
been  partly  absorbed  and  the  eye  has  shown  itself  toler- 
ant of  the  operation,  more  free  incisions  may  be  made  in 
the  capsule. 

The  needle  having  been  withdrawn,  the  eye  is  closed 
for  a  few  hours  with  a  simple  dressing,  or  absorbent  cot- 
ton and  a  Liebreich  bandage,  and  kept  under  a  mydriatic 
until  entirely  free  from  redness  or  irritability,  and  until 
all  pieces  of  lens-substance  that  may  fall  into  the  anterior 
chamber  have  been  absorbed.  Whenever  the  process  of 
absorption  ceases,  as  it  does  in  two  to  ten  weeks,  the 
operation  is  to  be  repeated,  the  lens  being  each  time  more 
completely  broken  up.  Discission  is  not  devoid  of  danger. 
The  slight  corneal  wound  may  become  the  seat  of  infec- 


COMMON  OPERATIONS.  559 

tion.  Hence,  strict  precautions  must  be  observed  to  avoid 
bruising  and  to  keep  it  aseptic.  If  the  opening  in  the 
capsule  be  too  large,  excessive  swelling  of  the  lens  occurs, 
and  may  cause  glaucoma.  If  pieces  of  comparatively 
unaltered  lens-substance  fall  into  the  anterior  chamber, 
they  cause  hyperemia  of  the  iris,  ciliary  body  and  peri- 
corneal  zone.  Lens-substance  that  has  been  previously 
disintegrated,  by  exposure  to  the  aqueous  within  the  cap- 
sule, causes  less  disturbance. 

CapSUlotomy. — Division  of  the  remaining  lens-cap- 
sule is  necessary,  in  the  majority  of  cases,  to  give  the  best 


FIG.  177.— Lines  for  the  T-shaped  or  inverted  V-shaped  incision  of  the  capsule 
for  secondary  cataract. 

possible  vision  after  removal  of  the  cataract.  The  opera- 
tion differs  from  discission,  as  above  described,  in  always 
aiming  at  a  free  division  of  the  membrane  which  obstructs 
the  pupil.  On  this  account,  to  give  the  longest  sweep  to 
the  cutting  edge,  to  reduce  the  bruising  and  twisting  of 
the  needle  in  the  cornea,  and  to  get  immediate  closure  of 
the  little  wound  and  guard  against  infection,  the  knife- 
needle  should  be  introduced  through  the  limbus,  where 
the  cornea  is  overlapped  by  vascular  sclera  and  conjunc- 
tiva. To  secure  gaping  of  the  opening,  it  is  generally 
necessary  to  make  incisions  meeting  at  an  angle.  But 
after  the  first  has  been  made,  the  membrane  becomes  re- 
laxed, so  that  unless  it  has  been  carefully  planned,  the 
second  incision  may  be  very  difficult  to  make.  A  good 
plan  is  illustrated  in  Fig.  177.  The  needle  entering  the 
limbus  at  A  is  made  to  pierce  the  membrane  at  B,  and 
then  to  cut  it  to  C.  It  is  then  slightly  withdrawn  and 
made  to  pierce  the  membrane  at  D,  and  to  cut  out  to  B  C, 


560  CAPSULOTOMY. 

near  C.  When  an  extensive  adhesion  exists  between  the 
iris  and  the  capsule,  incisions  should,  if  convenient,  pass 
through  its  base,  giving  freedom  to  the  iris  and  securing 
retraction  of  the  membrane. 

If  the  pupillary  membrane  be  excessively  thick  and 
tough,  so  that  a  careful  sawing  cut  will  not  give  a  good 
opening,  it  may  be  torn  from  the  center  by  double  trac- 
tion either  by  two  needles  introduced  at  the  two  margins 
of  the  cornea  (Bowman's  operation),  or  by  two  blunt 
hooks  introduced  from  the  two  sides  and  caught  in  a 
central  slit  (Noyes),  or  a  piece  may  be  removed  by  an 
operation  similar  to  iridotomy  (page  552).  Sometimes  the 
pupil  will  contain  a  thick  mass  left  by  imperfect  absorp- 
tion of  the  lens,  which  is  best  extracted  through  a  small 
corneal  incision,  by  piercing  with  a  sharp  hook  and 
twisting  it  until  it  is  rolled  up  and  freed  from  its  connec- 
tions. 

Removal  of  the  lens  for  high  myopia  is  effected 
by  discission  to  render  the  lens  opaque  and  lessen  its  ad- 
hesion to  the  capsule  ;  and  extraction  of  the  mass  of  lens- 
substance,  before  the  swelling  of  the  lens  or  escape  of 
lens-matter  into  the  anterior  chamber,  causes  serious 
hyperemia.  The  free  division  of  the  lens  at  the  first 
operation,  advocated  by  Fukala  and  others,  is  attended 
by  unnecessary  danger  to  the  eye,  and  is  followed  by  slow 
recovery.  If  hyperemia  commences  it  will  be  better  to 
extract  at  once  so  much  as  possible  of  the  lens  while  still 
clear,  rather  than  wait  till  it  becomes  entirely  opaque. 
If  the  bulk  of  the  lens  is  removed,  the  portions  remain- 
ing can  swell  and  disintegrate  without  causing  much 
trouble. 

OPERATIONS  ON  THE  EYEBALL. 

Magnet-extraction. — Magnets  used  to  extract  par- 
ticles of  steel  from  the  eye  are  of  three  kinds :  Strong 
permanent  mac/net*  may  be  used  to  remove  small  particles 
of  steel  from  the  front  of  the  eye,  where  the  magnet  can 
be  brought  in  contact  with  them.  Portable  electro-magnets, 
like  Hirschberg's,  have  straight  and  curved  points  that  are 


COMMON  OPERATIONS.  561 

sterilized  and  introduced  into  the  eye ;  where  they  attract 
the  particle,  which  may  sometimes  be  heard  to  strike 
the  point  with  a  click.  They  are  then  drawn  out,  with 
the  foreign  body  adhering.  Very  large  fixed  electro- 
magnets were  proposed  by  Haab.  They  are  intended  to 
attract  the  particle  and  draw  it  out  of  the  eye  through 
the  wound  of  entrance ;  or  to  draw  it  around  the  crystal- 
line lens  into  the  anterior  chamber,  whence  it  can  be 
extracted. 

For  extraction  with  the  portable  magnet,  the  eye  and 
the  magnet-tip  having  been  rendered  aseptic,  the  eye 
may  be  anesthetized  and  the  wound  of  entrance,  if  favor- 
ably situated,  somewhat  enlarged.  If,  however,  the  par- 
ticle has  entered  through  the  cornea  and  lodged  in  the 
vitreous,  it  will  be  best  to  make  an  incision  through  the 
sclera  for  the  introduction  of  the  point  of  the  Hirschberg 
magnet.  This  incision  is  to  be  made  as  close  as  possible 
to  the  location  of  the  foreign  body,  determined  as  ac- 
curately as  possible  by  the  ophthalmoscope  or  X-rays. 
It  should  be  large  enough  to  allow  the  withdrawal  of 
the  foreign  body,  with  some  of  the  tissue  surrounding  it. 
The  magnet-tip  is  introduced  in  first  one  direction,  and 
then  withdrawn  to  see  if  the  foreign  body  has  been  caught. 
If  not,  it  is  introduced  in  a  slightly  different  direction  for 
a  new  trial.  This  is  continued  until  the  particle  is  found, 
or  the  search  deemed  hopeless.  Small  particles,  being  but 
feebly  attracted,  are  most  difficult  to  dislodge.  After  the 
particle  is  withdrawn,  and  the  injured  or  affected  tissue  is 
cut  away,  the  incision  may  be  closed  with  sutures,  and 
treated  as  a  perforating  wound  of  the  eyeball. 

Enucleation  of  the  Eye. — If  the  eye  be  free  from 
inflammation,  this  operation  may  be  done  under  local 
anesthesia,  although  not  without  some  pain.  But  most 
eyes  requiring  enucleation  are  inflamed  and  for  them  a 
general  anesthetic  is  necessary.  The  lids  being  retracted 
by  the  speculum,  the  conjunctiva  is  seized  and  divided 
around  the  corneal  margin.  The  conjunctiva  is  then 
pushed  back,  and  witli  firm  pressure  the  forceps  are  made 
to  seize  the  tissue  of  the  insertion  of  the  internal  rectus. 


562  ENUCLEATION  OF  THE  EYE. 

The  strabismus-hook  is  then  passed  beneath  the  tendon, 
and  it  is  divided  with  the  scissors  about  3  mm.  back 
from  its  insertion.  The  stump  so  left  gives  a  firm  hold 
for  the  fixation-forceps.  The  strabismus-hook  is  now 
passed  downward  from  the  insertion  of  the  interims, 
breaking  up  the  loose  tissue  it  encounters,  until  it  passes 
beneath  the  inferior  rectus  tendon,  which  is  hooked  up 
and  divided  at  its  insertion.  The  hook  is  then  in  the 
same  way  passed  under  the  tendons  of  the  external  and 
superior  recti  muscles,  which  are  similarly  divided. 

The  anterior  portion  of  the  globe  having  thus  been 
quite  freed  from  all  attachments,  the  speculum  may 
be  removed  and  the  lids  retracted  by  the  fingers.  The 
eyeball  is  then  strongly  rotated  outward,  and  the  tissues 
pushed  back  at  the  nasal  side  of  the  globe  until  with  the 
tip  of  the  finger  a  thick  tense  cord  of  tissue  is  felt,  the 
optic  nerve.  The  blunt,  strong,  curved,  "  enucleation- 


FIG.  178.— Enucleation-scissore. 

scissors"  (Fig.  178)  are  now  introduced  with  the  points 
closed,  and  made  to  push  aside  the  tissue  on  either  side 
of  the  nerve.  The  nerve  is  then  included  between  the 
blades  and  divided  by  one  strong  cut. 

The  eyeball  is  now  dislocated  in  front  of  the  lids,  and, 
while  turned  out,  all  adherent  tissue  is  divided  close  to 
the  globe  by  successive  snips.  The  enucleated  eye  should 
be  dropped  in  a  4  per  cent,  solution  of  formaldehyd  (10 
per  cent,  formalin),  to  preserve  it  for  subsequent  care- 
ful examination. 


COM  PLICA  TIONS.  563 

To  secure  increased  motility  for  an  artificial  eye 
Priestley  Smith,  before  doing  enucleation,  stitches  each 
of  the  recti  tendons  to  the  overlying  conjunctiva,  by 
raising  the  tissues  with  fine-toothed  fixation-forceps,  and 
passing  a  suture  through  the  fold. 

Complications  and  Cautions. — The  removal  of  an 
eye  having  normal  tension  and  attachments  is  one  of  the 
easiest  of  important  surgical  operations.  But  if  the  eye 
has  been  the  seat  of  chronic  inflammation,  it  may  be 
firmly  bound  down  in  all  directions  by  new-formed  con- 
nective tissue.  It  may  be  impossible  to  reach  the  inser- 
tions of  the  recti  tendons  until  a  zone  of  this  tissue  all 
around  the  cornea  has  been  divided  by  snips  with  scissors  ; 
and  the  tissue  between  the  tendons  may  be  so  dense  that 
in  the  process  of  dividing  it,  the  tendons  themselves  are 
divided  unnoticed.  If  the  globe  has  been  perforated,  and 
is  therefore  perfectly  soft,  the  sclera  falls  in  folds  that  are 
liable  to  be  cut  with  the  scissors ;  and  if  the  eye  is 
shrunken  and  soft  and  surrounded  with  cicatricial  tissue,  a 
good  deal  of  care  is  necessary  to  remove  it  neatly. 

In  enucleating  an  inflamed  eye  there  is  always  a  good 
deal  of  hemorrhage,  which  must  be  cleared  away  by  an 
assistant  during  the  earlier  part  of  the  operation.  After 
the  removal  of  the  speculum,  when  the  optic  nerve  has 
been  severed  and  the  adherent  tissue  is  being  trimmed 
away,  the  lashes  or  the  lid-margins  are  liable  to  be  snipped 
by  the  scissors  unless  carefully  guarded. 

When  the  eye  is  removed  because  it  contains  a  malig- 
nant growth,  as  much  of  the  optic  nerve  as  possible  should 
be  removed  with  it.  To  do  this  the  tissue  around  the 
nerve  is  pushed  aside  from  it,  with  the  closed  points  of 
the  scissors  back  nearly  to  the  optic  foramen,  and  the 
nerve  grasped  back  there  by  the  open  blades  for  division. 
The  error  of  enucleating  the  wrong  eye  has  been  com- 
mitted. 

After-treatment. — Free  hemorrhage  should  be  allowed 
after  this  operation,  particularly  if  there  has  been  some 
extension  of  inflammation  into  tissue  surrounding  the  eye. 
When  desirable  it  is  best  checked  by  injecting  very  hot 


564  TREATMENT  AFTER  ENUCLEATION. 

water  into  the  socket.  The  cavity  may  then  be  dusted 
with  iodoform  and  covered  with  absorbent  cotton.  The 
socket  should  then  be  washed  out  once  or  twice  daily,  and 
dusted  with  iodoform  until  after  four  or  five -days,  when 
all  dressings  may  be  discontinued. 

The  artificial  eye  may  be  fitted  as  soon  as  the  wound 
has  quite  healed,  in  the  second  or  third  week.  Its  wear- 
ing is  to  be  advised,  because  beside  cosmetic  reasons  it 
prevents  the  upper  lid  from  falling  over  the  lower,  and 
being  irritated  by  the  lashes.  To  insert  it  the  upper  lid 
is  drawn  out  and  the  larger  temporal  edge  of  the  shell 
slipped  up  under  it.  Then  the  lower  lid  being  drawn 
down,  the  other  edge  is  slipped  in  and  the  artificial  eye 
slides  into  place.  It  is  removed  by  pulling  down  the 
lower  lid  and  slipping  a  large  pin  under  the  lower  edge. 
It  should  always  be  removed  at  night  and  carefully 
cleansed.  An  artificial  eye  becomes  roughened  after  one 
or  two  years  of  continuous  wearing,  and  then  must  either 
be  repolished,  or  replaced  by  another.  In  selecting  an 
artificial  eye  it  should  be  compared  with  the  natural  eye 
in  a  strong  light,  where  a  difference  of  color,  or  of  size  of 
pupil  would  be  most  noticeable.  The  various  forms  of 
glass  eye  proposed  by  Snellen  seem  distinctly  superior  to 
the  older  form  of  a  simple  shell  for  use  after  enuclcation. 

Evisceration  of  the  eye  may  be  done  instead  of 
enucleation,  for  pain,  as  in  absolute  glaucoma ;  or  to  pre- 
vent sympathetic  disease,  although  it  is  not  proven  that 
for  the  latter  purpose  it  is  equally  efficient  with  enucle- 
ation. It  should  never  be  done  for  malignant  disease 
writhin  the  eye.  It  usually  furnishes  a  better  support  for 
an  artificial  eye  than  does  enucleation  ;  but  the  reaction 
and  pain  following  operation  are  greater,  and  the  healing 
is  more  prolonged. 

The  eye  is  transfixed  just  back  of  the  cornea  with  a 
Beer's  or  Graefe  cataract-knife,  which  is  made  to  cut  its 
way  out  at  the  upper  or  lower  margin  of  the  cornea.  An 
incision  including  the  whole  cornea  is  completed  with 
strong  scissors.  The  contents  of  the  sclera  are  then 
removed,  care  being  taken  that  no  particles  of  tissue 


COMMON  OPERATIONS.  565 

remain.  The  cavity  may  then  be  allowed  to  fill  with 
blood ;  or  the  bleeding  may  be  checked,  and  the  scleral 
surface  cauterized  with  carbolic  acid,  and  the  cavity  filled 
with  iodoform.  The  sides  of  the  solera  are  brought 
together  by  interrupted  sutures,  or  a  single  gathering- 
string  suture  is  run  around  it. 

A  layer  of  surgical  lint  is  laid  upon  the  eye,  and  iced 
cloths  applied  continuously  for  a  day  or  two  to  keep  down 
the  reaction. 

Implantation  of  an  artificial  vitreous  (Mules' 
operation)  is  intended  to  secure  a  spherical  stump,  resemb- 
ling a  shrunken  eyeball,  for  the  better  support  and  move- 
ment of  an  artificial  eye.  After  evisceration  a  hollow 
sphere  of  glass,  silver  or  aluminum  is  inserted  in  the 
scleral  cavity.  All  bleeding  must  first  be  checked.  The 
sclera  is  slit  vertically  above  and  below  to  admit  the 
sphere,  which  must  not  be  too  large.  The  sclera  is 
then  brought  together  in  a  vertical  line  by  a  row 
of  silk,  or  silkworm-gut  sutures,  the  angles  of  tissue 
formed  above  and  below  being  neatly  trimmed  down. 
Then  the  conjunctiva  is  brought  together  over  the  sclera 
by  a  horizontal  row  of  sutures.  If  the  primary  closing 
of  the  scleral  opening  is  incomplete  the  sphere  will  not 
be  retained. 

Some  operators  implant  such  a  globe  in  the  cavity  left 
after  enucleation.  Bryant  has  employed  a  fenestrated 
globe  of  aluminum,  which  fills  with  granulation-tissue, 
securing  its  retention. 

BIBLIOGRAPHY. 

Operations  Usually  Performed  in  Eye  Surgery.   H.  Knapp,  "  System 

of  Diseases  of  the  Eye,"  vol.  iii. 
Best  Methods  of  Sterilizing  Instruments  and  Solutions.     E.  A.  de 

Schweinitz,  "  Trans.  Sect,  on  Oph.,  Amer.  Med.  Assoc.,"  1897. 
Continuous  Sterilization  of  Cutting  Instruments.     J.  A.  Lippincott, 

"Archives  of  Ophthalmol.,"  July,  1898. 
Sterilization  of  Instruments  with  Formaldehyd.  H.  O.  Reik,  "Johns 

Hopkins  Hosp.  Bulletin,"  Dec.,  1897. 
Aseptic  Treatment  of  Wounds  in  Ophthalmic  Surgery.     A.  McGil- 

livray,  "Trans.  Ophthal.  Soc.  of  the  United  Kingdom,"  Mar., 

1898. 


566  BIBLIOGRAPHY, 

Holocain.     J.  Hinshelwood,  "Ophthalmic  Review,"  July,  1898;  R 

L.  Randolph,  "Bull.  Johns  Hopkins  Hosp.,"  July,  1898. 
Infiltration  Anesthesia.     H.  V.  Wiirdemann,  "Trans.  Sect,  on  Oph- 

thalmol.,  Amer.  Med.  Assoc.,"  1895. 
Nursing  in  Eye  Diseases.     C.  S.  Jeaffireson,  90  pages.    John  Wright 

&  Co.,  Bristol. 

Plastic  Operations  on  the  Eyelids.     M.  W.  Zimmerman,  W.  B.  John- 
son, F.  C.  Hotz,  H.  Knapp,  and  H.  Harlan,  "Trans.  Sect,  on 

Ophthalmol.,  Amer.  Med.  Assoc.,"  1895. 
Use   of  Egg   Membrane  in  Ophthalmic   Surgery.     D.  H.   Coover, 

"Ophthal.  Record,"  May,  1899. 
Operations  on  the  Eyelids.      F.  C.  Hotz,  "  American  Text-book ; " 

G.  C.  Harlan,  "System  of  Diseases  of  the  Eye,"  vol.  iii. 
Operations  on  the  Eye  Muscles.  S.  C.  Ay  res,  "  American  Text-book." 
Operation  for  Ptosis.     P.  H.  Mules,  "  Trans.  Ophthalmol.  Soc.  of 

United  Kingdom,"  May,  1895. 
Complete  Keratectomy.     P.  Panas,   "Ophthalmic  Review,"   Sept., 

1898. 
Operations  on  the  Conjunctiva,  Cornea  and  Sclera,  Enucleation  etc. 

C.  W.  Kollock,  "  American  Text-book." 
Report  on  Relative  Value  of  Simple  Excision  of  the  Eyeball,  and 

the  Operations  which  have  been  Substituted  for  it.     "  Trans. 

Ophthal.  Soc.  of  the  United  Kingdom,"  1897-98. 
Motility   and    Position    of   the    Artificial    Eye   after   Enucleation. 

Priestley  Smith,  "Ophthal.  Review,"  May,  1899. 
Implantation    of  Glass  ball    and   Mules'   Operation.     L.  W.   Fox, 

"  Trans.  Sect,  on  Ophthalmol.,  Amer.  Med.  Assoc.,"  1897. 
Artificial  Eyeballs.    H.  Snellen,  "Ophthalmic  Review,"  Dec.,  1898. 
Ophthalmic  Operations  as  Practiced  on  Animals'  Eyes.   C.  A.  Veasey, 

100  pages.     Edwards  and  Docker,  Philadelphia. 


CHAPTER  XX. 

OCULAR  SYMPTOMS  AND  LESIONS  CONNECTED 
WITH  GENERAL  DISEASES. 

THE  detailed  descriptions  of  the  symptoms  and  lesions 
here  mentioned  are  given  in  preceding  chapters,  and  must 
be  referred  to  as  mentioned  here,  if  the  reader  wishes  to 
get  a  complete  clinical  picture  of  the  ocular  manifestations 
of  any  particular  disease. 


OCULAR  SYMPTOMS  OF  DISEASE.  567 


DISEASES  OF  THE   NERVOUS  SYSTEM. 

Organic  diseases  of  the  brain  and  its  meninges, 

including  tumor,  meningitis,  abscess,  aneurysm,  trauma- 
tism,  cerebritis,  softening,  hemorrhage,  embolism,  and 
thrombosis,  are  all  liable  to  cause  optic  neuritis  (see 
page  385).  It  is  therefore  of  very  little  value  to  dif- 
ferentiate these  various  conditions,  but  it  proves  that  the 
symptoms  present  do  arise  from  organic  disease. 

Intracranial  disease  also  causes  abnormalities  of  the 
pupils  (page  72),  palsies  or  spasms  of  the  ocular  muscles 
(page  204),  or  limitation  of  the  fields  of  vision  (pages  36,  47, 
391),  which  may  be  either  transient  (remote  symptoms) 
or  permanent,  directly  due  to  the  lesion.  When  perma- 
nent, they  are  of  the  highest  value  in  localizing  the  disease. 

The  above  symptoms  in  themselves  give  no  positive 
information  as  to  the  nature  of  the  morbid  process  caus- 
ing them,  as  whether  a  tumor  is  syphilitic  or  tubercular. 
But  the  close  anatomical  and  physiological  relationships 
between  eye  and  brain  make  them  often  suffer  from  a 
common  cause  ;  and  the  concomitant  eye-lesion  may  sug- 
gest with  great  probability  the  nature  of  the  cerebral  pro- 
cess. Diseases  of  the  retina  and  choroid  are  of  greatest 
importance  in  this  connection. 

Optic  atrophy  attending  brain  disease,  if  consecutive 
(page  391),  has  the  same  significance  as  optic  neuritis. 
But  if  primary  it  may  point  to  pressure  on  the  tracts  or 
nerves,  in  which  case  it  has  localizing  value ;  or  it  may 
indicate  that  the  trouble  is  of  toxic  origin  (page  397),  or 
it  may  belong  to  a  disseminated  sclerosis.  Progressive 
involvement  of  one  ocular  muscle  after  another,  or  of 
different  parts  of  the  visual  field  have  great  prognostic 
significance.  The  former  may  characterize  a  form  of 
progressive  bulbar  paralysis.  Nystagmus  appears  fre- 
quently in  multiple  sclerosis,  but  it  may  also  appear  in 
any  case  of  prolonged  severe  impairment  of  vision.  Grave 
cerebral  hemorrhage,  embolism  or  thrombosis  is  often 
attended  with  hemorrhage  or  vascular  disease  of  the 
retina  of  the  affected  side. 


568  DISEASES  OF  NERVOUS  SYSTEM. 


SYMPTOMS  OFTEN   EXPLAINED   BY   OCULAR 
EXAMINATIONS. 

Coma  should  always  lead  to  a  thorough  objective  ex- 
amination of  the  eyes.  If  uremic,  albumin  uric  retinitis 
may  be  found  (page  365) ;  if  narcotic,  extreme  equal 
myosis  without  other  symptoms  ;  if  apopletic,  myosis  and 
inequality  of  the  pupils  may  be  remarked,  with  conjugate 
deviation  of  the  eyes.  Organic  brain  disease  may  be 
revealed  by  optic  neuritis ;  or  mydriatic  poisoning,  by 
extreme  dilatation  of  the  pupils.  Convulsions  and  de- 
lirium may  be  referred  to  their  cause,  by  the  same  ocular 
symptoms. 

Headache,  if  persistent  or  frequently  recurring,  should 
always  evoke  careful  investigation  of  the  eyes.  Eye- 
strain  is  its  most  common  cause  (page  53) ;  or  it  may  be 
due  to  organic  brain  disease  that  will  be  revealed  by  optic 
neuritis  or  atrophy,  or  to  uremia  or  other  conditions  that 
are  attended  by  characteristic  retinitis. 

Vertigo,  and  often  nausea,  may  arise  from  the  causes 
mentioned  for  headache.  They  may  also  be  caused  by 
paresis  of  one  or  more  ocular  muscles,  or  from  strain  of 
these  muscles,  as  in  excessive  convergence  from  high 
myopia. 

Sclerosis  of  the  Spinal  Cord. — In  posterior  sclero- 
sis (locomotor  ataxia,  tabes  dorsalis),  primary  gray  optic 
atrophy  (page  395),  with  corresponding  visual  impair- 
ment, occurs  in  between  ten  and  thirty  per  cent,  of  all 
cases.  In  a  few  cases  it  antedates  all  other  symptoms, 
sometimes  by  many  years.  Sometimes  it  appears  shortly 
after  the  lightning  pains,  gastric  crises,  or  ataxic  symp- 
toms ;  and  in  these  cases  the  progress  of  the  ataxia  is  apt 
to  be  arrested,  and  the  power  of  locomotion  to  remain 
good  for  a  long  time.  Occurring  in  the  later  stages,  the 
atrophy  progresses  with  the  ataxia. 

In  a  similar  proportion  of  cases  of  sclerosis,  paresis  or 
paralysis  of  one  or  more  ocular  muscles  occurs.  This  may 
also  be  an  early  symptom.  Such  palsies  appear  suddenly. 
They  may  be  quite  transient,  or  permanent.  The  loss  of 


OCULAR  SYMPTOMS  OF  DISEASE.  569 

light-reflex  of  the  pupil  (Argyll-Robertson  pupil,  page 
74),  and  the  less  definite  condition  of  myosis  are  among 
the  most  important  early  symptoms  of  tabes.  The  former 
occurs  in  three-fourths  of  all  cases,  and  in  very  few  does 
the  pupil  remain  normal.  Epiphora  is  a  frequent  symp- 
tom, being  sometimes  due  to  relaxation  of  the  lid,  some- 
times to  hypersecretion. 

Acute  myelitis  has  been  attended  with  double  optic 
neuritis  (page  385).  In  spinal  injuries  and  caries,  hyper- 
emia  and  anemia  of  the  disk  (pages  383  and  384),  have 
been  noted,  but  are  not  significant.  Involvement  of  the 
cord  or  of  the  nerve-roots  in  the  cervical  region  may 
cause  myosis  and  slight  ptosis,  through  paralysis  of  the 
cervical  sympathetic,  or  spastic  mydriasis,  widening  of 
the  palpebral  fissure,  and  apparent  exophthalmos  from  an 
irritative  lesion  (page  56). 

Disease  of  the  trifacial  nerve  may  be  accom- 
panied by  neuroparalytic  keratitis  (page  287),  or  it  may 
cause  herpes  zoster  (page  288).  In  all  cases  of  neuralgia 
aifecting  the  ophthalmic  division,  the  possibility  of  glau- 
coma should  be  carefully  considered. 

Multiple  neuritis  may  include  an  axial  neuritis  of 
the  optic  nerve  causing  central  scotoma  (page  40),  or  may 
produce  palsies  of  isolated  ocular  muscles  (page  204). 

Epilepsy. — The  attack  may  open  with  a  visual  aura, 
like  that  of  migraine.  There  may  be  concentric  narrow- 
ing of  the  fleld  of  vision,  or  lowered  acuteness  of  vision 
after  the  attacks,  and  sometimes  before  them.  Narrow- 
ing of  the  retinal  arteries  has  been  noted  at  the  beginning 
of  the  attack,  and  marked  distention  of  the  retinal  veins 
at  the  close,  or  following  the  seizure.  The  ocular  mus- 
cles may  participate  in  the  movements,  associated  move- 
ments of  the  two  eyes  being  especially  common.  Sub- 
conjunctival  ecchymoses  may  be  produced,  and  partial 
opacity  of  the  lens  or  complete  cataract  may  arise. 

Epileptiform  seizures  seem,  in  rare  cases,  to  be  due  to 
eye-strain,  and  to  cease  when  it  is  relieved. 

Tetany  has  been  connected  with  a  form  of  cataract 


570  TETANY. 

in  which  the  opacity  begins  before  middle  life  and  is  long 
confined  to  the  nucleus. 

Migraine. — The  attacks  of  pain  are  in  many  cases 
preceded  by  scintillating  scotoma  (page  45),  or,  in  rare 
cases,  this  is  replaced  by  a  distinct  visual  hallucination. 
These  visual  disturbances  do  not  usually  occur  with  every 
migrainous  attack,  but  only  with  an  occasional  seizure. 
Sometimes  they  constitute  the  whole  attack.  They  may 
attend  the  attacks  for  a  time,  the  migraine  having  existed 
before  or  continuing  afterward  without  any  such  visual 
phenomena. 

In  a  large  proportion  of  cases  migraine  depends  upon 
or  is  aggravated  by  eye-strain,  and  is  partially  or  com- 
pletely relieved  by  the  careful  correction  of  ametropia 
(pages  153,  185).  Patients  who  have  the  visual  disturb- 
ance are  especially  likely  to  think  of  their  attacks  as 
connected  with  ocular  defects.  But  it  is  not  certain  that 
the  connection  is  closer  or  more  general  among  these  cases 
than  among  others.  Optic  atrophy  (page  391)  has  some- 
times been  associated  with  migraine,  but  more  frequently 
glaucoma  has  been  mistaken  for  such  an  association. 

Chorea. — The  acute  chorea  of  childhood,  chorea 
minor,  may  be  attended  with  irregular  action  of  the  eye- 
muscles,  but  is  not  caused  by  muscular  anomalies.  Habit- 
choreas,  habit-spasms,  or  reflex  choreic  movements,  may 
be  caused  by  eye-strain  and  cured  by  its  relief.  Severe 
eye-strain  may  also  be  an  important  agency  in  causing  the 
depressed  condition  of  the  nervous  system,  which  predis- 
poses to  chorea.  Retinal  embolism  (page  374)  has  oc- 
curred in  connection  with  chorea. 

Exophthalmic  goiter  has  already  been  considered 
(page  472).  The  ocular  symptoms  are  not  essential,  but 
are  usually  the  most  striking  manifestation  of  the  dis- 
ease. 

Akromegaly. — The  hypertrophy  may  involve  the 
bones  of  the  orbit  and  the  skin  of  the  lids.  The  ocufor 
movements  and  reactions  of  the  pupils  are  often  slow  or 
slightly  irregular.  There  may  be  paralysis  of  one  or 
more  ocular  muscles  or  impairment  of  central  vision,  and 


OCULAR  SYMPTOMS  OF  DISEASE.  571 

irregular  contraction  of  the  visual  field  (page  41).  The 
most  characteristic  ocular  symptom,  though  far  from  con- 
stant, is  bitemporal  contraction  of  the  visual  fields,  or 
hemianopsia  (page  37),  probably  from  pressure  of  the  en- 
larged pituitary  body  upon  the  optic  chiasm.  Irregular 
or  unsymmetrical  contraction  of  one  or  both  fields  occurs 
from  the  same  cause  ;  exophthalmos,  double  optic  neuritis, 
optic  atrophy,  nystagmus,  and  hypersecretion  of  tears 
have  been  reported. 

Mind-blindness,  inability  to  receive  a  mental  im- 
pression from  objects  seen ;  word-blindness,  inability 
to  recognize  written  or  printed  words ;  letter-blindness, 
inability  to  name  letters,  although  words  are  understood ; 
and  dyslexia — or  an  insurmountable  difficulty  in  read- 
ing, although  the  patient  possesses  perfect  sight  and  can 
read  a  few  words  at  a  time — are  conditions  of  important 
significance,  liable  to  be  confused  with  impairment  of 
vision. 

Neurasthenia  is  attended  with  pain  connected  with 
use  of  the  eyes,  variable  heterophoria,  deficient  power  of 
abduction,  adduction  and  sursumduction  (page  192),  twitch- 
ing of  the  lids,  large  but  mobile  pupils,  and  persistent 
after-images.  Concentric  contraction  of  the  field  of  vision, 
which  rapidly  increases  while  the  field  is  being  taken ; 
and  impairment  of  central  vision  are  sometimes  found. 
The  patient  experiences  much  annoyance  from  the  effects 
of  low  ametropia,  and  corresponding  relief  from  its  cor- 
rection. The  optic  disk  is  hyperemic  (page  93).  Eye- 
strain  may  be  a  most  important  factor  in  causing  neura- 
sthenia. 

Insanity  may  be  attended  with  visual  hallucinations. 
It  presents  no  ocular  symptoms  characteristic  of  the  con- 
dition in  general,  or  of  any  particular  form  of  insanity. 
Ocular  symptoms  connected  with  some  causative  or  con- 
comitant condition,  like  albuminuria,  syphilis,  or  tabes, 
are  common. 

Hysteria  may  present  many  eye-symptoms.  The 
more  characteristic  of  these  are  progressive  concentric 
contraction  of  the  field  of  vision,  like  that  of  neura- 


572  HYSTERIA. 

thenia,  contraction  of  the  color-fields  or  reversal  of  their 
normal  order,  amblyopia  or  complete  blindness  of  one 
eye  (page  403),  squint  (page  234),  blepharospasm,  dilata- 
tion or  contraction  of  one  pupil  (page  76),  monocular 
diplopia  without  evident  ocular  cause  (page  46),  asthen- 
opia,  and  complaints  of  inability  to  use  the  eyes  or  wear 
glasses.  Eye-strain  may  be  a  contributory  or  exciting 
cause  of  hysteria. 

DISEASES  OF  THE  CIRCULATORY  SYSTEM  AND 
KIDNEYS. 

Anemia,  if  severe,  causes  characteristic  ophthalmic 
changes.  If  acute,  as  from  hemorrhage,  the  patient  may 
become  suddenly  blind,  with  ophthalmoscopic  changes 
(page  384),  that  later  may  go  on  to  those  of  optic  atrophy 
(page  391),  although  at  least  partial  recovery  of  sight  is 
the  rule.  Chronic  simple  anemia  presents  a  pearly-white 
sclerotic,  and  pallor  of  the  inner  surface  of  the  lids.  The 
fundus  of  the  eye  appears  pale  throughout,  the  retinal 
arteries  are  slightly  narrowed.  The  retinal  veins  are  pale 
but  very  broad,  with  a  broad  light-streak  (page  86). 

leukemia  and  pernicious  anemia  may  present  the 
appearance  of  simple  anemia,  with  even  greater  pallor  of 
the  fundus.  In  severe  cases  there  exists  generally  the 
characteristic  retinitis  or  neuroretinitis  with  retinal 
hemorrhages  (page  363) ;  lymphoid  tumors  of  the  lid  and 
orbit,  and  chloroma  (page  476)  are  sometimes  associated 
with  leukemia. 

Diseases  of  the  Heart. — Aortic  regurgitation  caus- 
ing a  sudden  drop  in  the  arterial  pressure  is  liable  to 
cause  pulsation  of  the  retinal  arteries  (page  86).  Similar 
pulsation  may  be  caused  by  syncope.  It  may  also  be 
noticed  in  sudden  overaction  of  the  heart  from  excite- 
ment, and  rarely  in  exophthalmic  goiter.  Distention  of 
the  right  heart  and  the  venous  system  may  cause  disten- 
tion  and  tortuosity  of  the  retinal  veins  (page  92).  Endo- 
carditis may  give  rise  to  embolism  of  the  central  retinal 
artery.  General  edema  due  to  heart  disease,  although 


OCULAR  SYMPTOMS  OF  DISEASE.  573 

not  especially  liable  to  involve  the  eyelids,  may  be  noticed 
there  upon  rising  in  the  morning. 

Aneurysm  of  the  aorta  or  innominate  may  give 
rise  to  embolism  of  the  retinal  artery  (page  374),  and  to 
dilatation  of  the  pupil  and  widening  of  the  palpebral  fis- 
sure and  exophthalmos  through  irritation  of  the  cervical 
sympathetic.  Aneurysm  of  the  internal  carotid  may 
cause  palsies  of  ocular  muscles  (page  204)  ;  and  if  it  burst 
into  the  cavernous  sinus,  it  causes  pulsating  exophthalmos 
(page  472). 

Renal-vascular  Disease.  —  Albuminuric  retinitis 
(page  365)  occurs  chiefly  when  after  a  period  of  high 
arterial  tension  the  circulation  begins  to  fail.  The  retinal 
lesions  are  so  directly  connected  with  the  vascular  condi- 
tion, and  the  retinal  vessels  are  so  largely  affected  in  the 
process,  that  it  would  belong  more  properly  with  circulatory 
than  with  renal  disorders.  In  some  cases  no  albumin  may 
be  found  in  the  urine,  and  no  symptoms  of  kidney  disease 
may  be  noticed,  but  chronic  advanced  angiosclerosis  is 
always  present.  The  kidney  disease  with  which  it 
usually  occurs  is  chronic  interstitial  nephritis,  although 
albuminuric  retinitis  may  attend  the  large  white  kidney, 
acute  nephritis,  or  the  albuminuria  of  pregnancy. 

Retinal  hemorrhage  (page  360),  so  marked  a  feature 
of  albuminuric  retinitis,  may  occur  without  other  retinal 
changes,  and  may  be  followed  by  hemorrhagic  glaucoma 
(page  444).  Detachment  of  the  retina  (page  377)  some- 
times occurs,  but  retinal  edema  may  be  taken  for  a 
limited  detachment.  Paralyses  of  ocular  muscles  occur 
in  rare  cases,  and  the  eye-muscles  participate  in  eclampsia. 

Uremic  amaurosis  (page  402)  is  sudden  in  its  onset, 
and  usually  complete,  but  the  pupils  continue  to  react  to 
light.  Edema  due  to  renal  disease  is  often  most  notice- 
able in  the  eyelids,  but  it  may  exist  without  affecting  the 
lids. 

Albuminuric  retinitis,  retinal  hemorrhage,  and  palsies  of 
the  ocular  muscles  indicate  an  early  fatal  termination  of 
the  disease.  But  few  patients  survive  two  years  after 
marked  retinitis  is  noticed. 


574  RENAL  DISEASE. 

Diabetes  causes  cataract  which  resembles  other  cat- 
aracts in  persons  of  similar  age,  except  for  a  diffuse 
clouding  of  the  lens  which  may  vary  with  the  general 
condition  of  the  patient.  Diabetics  are  sometimes  sub- 
ject to  sudden  and  great  changes  in  the  refraction  of  the 
eye,  closely  connected  with  changes  in  the  amount  of 
sugar  in  the  urine.  Diabetic  retinitis  (page  368),  although 
rare,  is  a  characteristic  condition.  Retinal  hemorrhage 
(page  360)  is  common.  Central  scotoma  especially  for  red 
and  green,  due  to  retrobulbar  axial  neuritis  (page  391), 
is  met  with ;  and  optic  atrophy  may  follow.  Palsies  of 
the  ocular  muscles  occur,  commonly  incomplete ;  and  the 
accommodation  may  be  paralyzed. 


DIATHETIC  DISEASES. 

Rheumatism. — The  characteristics  of  rheumatic  iritis 
have  already  been  deseribed  (page  319).  Cyditis  may  also 
occur.  A  mild  cyclitis  probably  more  often  than  iritis 
accompanies  acute  attacks  of  articular  rheumatism.  Ocu- 
lar palsies  (page  204)  arise  from  rheumatic  disease  of  the 
nerve-trunks.  But  many  cases  loosely  classed  as  rheu- 
matic are,  probably,  simply  neuritis  from  cold  or  other 
non-rheumatic  cause.  Rheumatic  endocarditis  is  a  chief 
cause  of  embolism  of  the  central  artery  of  the  retina  (page 
374).  Chronic  rheumatic  inflammation  may  affect  the 
white  fibrous  tissue  of  the  eye  in  the  form  of  scleritis  or 
episcleritis  (page  311).  The  conjunctiva  may  participate 
in  such  an  inflammation,  but  there  is  no  conjunctiva]  dis- 
charge. 

Gout. — Gouty  inflammation  of  retina,  optic  nerve,  and 
ehoroid  (page  368),  although  clinically  distinct  from  both, 
is  closely  allied  to  diabetic  and  albuminuric  retinitis,  and 
of  similar  grave  prognostic  import.  Iritis,  due  to  gout 
(page  319),  is  insidious  and  tends  to  relapses.  Scleritis 
(page  311)  and  brief  periodic  episcleritis  (page  243)  seem 
to  be  associated  with  gout.  Glaucoma,  especially  simple 
glaucoma  (page  443),  occurs  in  persons  of  a  gouty  tend- 
ency, and  senile  cataract  has  been  ascribed  to  this  diathe- 


OCULAR  SYMPTOMS  OF  DISEASE.  575 

sis.  A  recurring  hyperemia,  or  dry  catarrh  of  the 
conjunctiva,  may  be  due  to  gout.  Superficial  painful 
ulcer  near  the  corneal  margin  occurring  in  old  people 
(page  286)  and  sclerotising  keratitis  are  also  regarded  as 
of  gouty  origin. 

Purpura  is  often  attended  with  retinal  hemorrhage, 
and  hemorrhage  may  occur  in  the  choroid,  conjunctiva, 
and  lids,  or  in  the  depth  of  the  orbit  where  it  would 
cause  exophthalmos.  Similar  hemorrhage  may  occur  in 
Scurvy,  although  few  cases  have  been  reported. 

Scrofula  or  struma  has  largely  been  merged  in 
tuberculosis.  But  there  are  certain  diseases  of  the  eye 
distinctly  associated  with  a  diathetic  condition  marked  by 
a  pasty,  inelastic,  rough  skin,  liable  to  eczematous  erup- 
tions, a  tendency  to  catarrhal  inflammations  of  the  mucous 
membranes,  disordered  digestion,  constipation,  foul  tongue, 
and  anemia.  These  diseases  are :  Marginal  blepharitis 
(page  449),  phlyctenular  conjunctivitis  (page  261),  and 
keratitis,  both  phlyctenular  and  interstitial  (pages  288 
and  292). 

CHRONIC  INFECTIOUS  DISEASES. 

Tuberculosis  of  the  eye  is  rare.  It  may  involve  the 
iris  (page  330),  or  the  choroid  (page  352),  with  distinct 
characteristic  tubercular  deposits.  It  may  affect  the  con- 
junctiva, causing  an  intractable  inflammation  and  thick- 
ening (page  268),  or  it  may  invade  the  lids,  as  lupus 
(page  461).  Tubercles  in  the  choroid  generally  occur  in 
a  late  stage  of  general  tuberculosis ;  but  the  disease  may 
be  primary,  or,  at  least,  antedate  other  manifest  lesions. 
Tubercular  disease  of  the  brain  causes  the  same  ocular 
symptoms  as  other  organic  brain  disease. 

Syphilis. — The  primary  sore  may  occur  on  the  lids 
(page  453)  ;  or  in  the  conjunctiva  (page  268),  especially  on 
the  caruncle  and  on  the  palpebral  portion.  The  secondary 
eruption  may  involve  the  lids,  or  cause  falling  of  the 
lashes  and  eyebrows ;  but  the  important  secondary  lesions 
are  those  of  the  uveal  tract.  Iritis  (page  319)  may  be 


576  SYPHILIS. 

the  earliest  of  secondary  symptoms,  or  one  of  the  latest. 
Cyclitis  (page  324)  is  of  much  the  same  significance. 
They  yield  well  to  specific  treatment.  Syphilitic  chor- 
oiditis,  choriarctinitis  (page  369),  optic  neuritis  (page  385), 
and  dust-like  opacity  of  the  vitreous  (page  427),  are  more 
intractable. 

Tertiary  syphilis  of  the  lids  causes  tarsitis  (page  450), 
and  in  both  the  lids  and  conjunctiva  ulcers  with  thick- 
ened margins  that  may  be  mistaken  for  cancer.  A  gumma 
may  occur  in  any  part  of  the  eye  or  its  appendages.  The 
more  important  lesions  of  the  kind  affect  the  iris  and  the 
ciliary  body  (page  330),  the  walls  of  the  orbit  (page  471), 
and  the  lacrimal  passages  (page  466)  Chorioretinitis 
(page  369),  retinitis  piymentosa  (page  372),  optic  neuritis 
and  atrophy  are  important  manifestations  in  this  stage. 
Glaucoma  (page  445)  may  arise  in  this  stage.  Palsies  of 
the  ocular  muscles  (page  204)  are  most  often  due  to  tertiary 
syphilis.  Syphilitic  disease  of  the  central  nervous  sys- 
tem, or  of  other  organs  of  the  body,  may  give  rise  to  the 
concomitant  eye-affections. 

Inherited  syphilis  is  the  cause  of  the  majority  of  cases 
of  interstitial  keratitis  (page  292),  and  the  accompanying 
iritis,  cyclitis,  and  choroiditis.  It  occasions  most  congen- 
ital opacities  of  the  cornea  (page  301),  and  may  cause  cat- 
aract and  vitreous  opacities.  It  may  give  rise  to  many 
of  the  lesions  of  tertiary  syphilis,  and  especially  to  reti- 
nitis pigmentosa,  and  disease  of  the  lacrimal  passages. 
The  Hutchinson  teeth  and  their  significance  are  discussed 
on  page  295. 

Gonorrhea,  by  local  infection  of  the  conjunctiva, 
causes  the  great  mass  of  cases  of  purulent  conjundivitis  in 
adults  (page  243),  and  of  the  ophthalmia  of  the  new- 
born (page  245),  with  their  complications  and  sequels  of 
suppuration  of  the  cornea  (page  278),  corneal  leucoma 
(page  301),  and  staphyloma  (page  305),  with  permanent 
blindness.  It  may  also,  either  with  or  without  gonor- 
rheal  rheumatism,  cause  a  mild  conjunctivitis  apparently 
without  infection. 

Iritis  due  to  gonorrhea  (page  319)  may  appear  early, 


OCULAR  SYMPTOMS  OF  DISEASE.  577 

apart  from  any  rheumatic  manifestations,  or  later  with 
joint  involvement.  In  the  former  case  it  is  very  acute, 
with  excessive  plastic  exudation,  but  yields  to  treatment 
and  ends  in  good  recovery.  In  the  latter  it  is  less  vio- 
lent, but  shows  a  tendency  to  relapse,  usually  in  connec- 
tion with  the  relapse  of  the  urethral  discharge,  and  the 
rheumatic  symptoms. 

T^eprosy  causes  destruction  of  the  lashes  and  eyebrows, 
anesthetic  patches,  and  nodules  in  the  lids ;  and  the  result- 
ing deformity  of  the  lid  may  cause  disease  of  the  cornea, 
pannus  (page  298).  The  disease  also  invades  directly  the 
conjunctiva  and  interior  of  the  eyeball.  The  limbus  is 
especially  the  seat  of  nodules.  Iritis  and  vitreous  opac- 
ity occur,  or  the  eye  may  be  lost  through  the  corneal 
anesthesia  and  neuroparalytic  ophthalmia  (page  287). 

Malaria. — Persons  who  have  suffered  from  malaria 
are  liable  to  certain  forms  of  chronic  keratitis  (page  286), 
and  malarial  neuralgias  often  involve  the  ophthalmic 
branch  of  the  trifacial  nerve.  Optic  neuritis  (page  385), 
usually  followed  by  partial  atrophy,  attends  the  tropical 
malarias.  Sudden  anemia  of  the  retina  may  occur  and  be 
followed  by  optic  atrophy.  Retinal  hemorrhages  (page 
360)  occur,  and  effusions  into  the  vitreous  (page  429).  A 
transient  retinochoroiditis  has  been  described  as  due  to 
malaria.  Sudden  amaurosis,  apart  from  the  use  of  quinin, 
has  also  been  reported. 

ACUTE  INFECTIOUS  DISEASES. 

All  these  diseases  may  be  attended  in  the  acute  febrile 
stage  by  hypercmia  of  the  conjunctiva,  (page  60),  and  pho- 
tophobia connected  with  meningeal  irritation. 

Measles  may  begin  as  an  acute  catarrhal  conjunctivitis 
(page  237).  Generally  the  conjunctiva  participates  in  the 
irritation  of  the  mucous  surfaces,  there  being  conjuncti- 
val  hyperemia,  photophobia,  and  increased  lacrimation. 
Toward  the  close  of  the  disease  and  afterward,  there 
may  remain  a  strong  tendency  to  chronic  conjunctivitis, 
catarrhal  (page  253)  or  phlyctenular  (page  261),  with  a 

37 


578  MEASLES. 

tendency  to  cornea!  ulceration  (page  276).  This  condition 
of  lowered  resisting  power  may  last  for  many  months. 
KeratoDialacia  (page  287)  has  been  observed.  There  may 
also  be  a  persistent  asthenopia  without  obvious  cause,  or 
excessive  annoyance  from  low  degrees  of  ametropia.  Men- 
ingitis may  cause  muscular  palsies,  optic  neuritis,  and 
blindness. 

Scarlatina,  while  less  frequently  attended  with  acute 
catarrhal  conjunctivitis  than  measles,  is  more  liable  to  be 
followed  by  serious  corneal  disease,  and  laerimal  disease, 
inflammation  of  the  gland  (page  467),  or  obstruction  of 
the  laerimal  passages.  It  is  also  liable  to  be  followed  by 
orbital  celluUtis  (page  468),  and  the  eye-complications  of 
meningitis.  But  the  most  important  ocular  lesions  due  to 
scarlet  fever  are  those  of  albumlnuric  retinitis  (page  365) 
and  associated  conditions. 

Diphtheria  may  attack  the  conjunctiva,  causing  the 
classical  diphtheritic  conjunctivitis  (page  250),  or  less 
violent  conjunctival  disease  with  destruction  of  the  cornea. 
More  frequent  is  the  diphtheritic  paralysis  of  accommoda- 
tion (page  333)  which  comes  on  after  convalescence  from 
the  throat-lesions  has  begun,  and  lasts  several  weeks. 
Partial  or  complete  palsies  of  the  extra-ocular  muscle  (page 
214)  are  not  rare.  They  are  seen  later,  sometimes  many 
months  after  the.  diphtheritic  attack.  Convergent  squint 
following  diphtheria  may  be  established  by  excessive 
efforts  during  the  period  of  weakened  accommodation. 

Influenza  is  followed  by  a  period  of  nervous  depres- 
sion, during  which  paresis  of  accommodation  (page  333)  and 
excessive  asthenopia  or  fatigue  from  use  of  the  eyes  are 
common.  In  a  few  cases  it  has  been  followed  by  narrow- 
ing of  the  field  of  vision  and  optic  atrophy  (page  391). 
The  writer  has  seen  lens-opaciti/  rapidly  increased  by  it. 
It  has  been  followed  by  orbital  cellulitis  (page  46<S). 
Glaucoma  has  been  ascribed  to  it, 

Smallpox  causes  blindness  through  suppurating  ror- 
ii/i-i'/-  (page  278)  which  appears  near  the  end  of  the 
second  week  of  the  disease,  never  in  the  early  stage. 
Such  ulcers  may  heal,  however,  without  perforation.  The 


OCULAR  SYMPTOMS  OF  DISEASE.  579 

primary  eruption  rarely,  or  never  affects  the  cornea ;  but 
it  may  appear  on  the  conjunctiva  and  lids,  and  cause  per- 
manent deformity  of  the  lid-margins  or  the  lashes  by  the 
scars. 

Vaccinia  occasionally  affects  the  eyelids,  causing  great 
swelling  and  induration  with  involvement  of  the  related 
lymphatic  glands.  One  or  more  pustules  form  and  run 
the  usual  course.  "  The  conjunctiva  at  the  height  of  the 
disease  may  present  a  croupous  deposit  (page  250),  but 
the  cornea  escapes  without  serious  injury.  The  scars 
cause  deformity  of  the  lid  or  trichiasis.  The  disease  is 
generally  due  to  direct  inoculation  ;  but  cases  have  been 
reported  in  which  the  lid-lesions  followed  inoculation  else- 
where. Vaccination  on  the  lids  has  been  resorted  to  pur- 
posely for  the  cure  of  nevus  (page  461). 

Chicken-pox  may  be  followed  by  subacute  catarrhal 
conjunctivitis  or  simple  corneal  ulcer. 

Whooping-cough,  by  the  violent  straining  of  the 
coughing  spells,  causes  hemorrhage  which  is  most  fre- 
quently located  under  the  ocular  conjunctiva  (page  270), 
but  which  may  occur  in  the  lids  or  orbit,  or  so  as  to 
involve  the  optic  nerve,  causing  blindness  by  optic  atrophy, 
or  may  produce  palsies  through  involvement  of  the  motor 
nerves. 

Mumps  may  cause  edema  of  the  lids  (page  459)  and 
chcmosis  through  the  proximity  of  the  swelling  of  the 
parotid  gland.  In  rare  cases  the  lacrimal  glands  are 
affected  (page  467).  Exophthalmos  and  impairment  of 
vision  have  been  noted. 

Cerebrospinal  meningitis  usually  affects  the  eyes. 
Conjunctivitis  occurs  in  most  -cases.  There  may  be  edema 
of  conjunctiva  and  lids,  and  other  evidences  of  venous 
congestion.  Thrombosis  of  the  retinal  vein  (page  377), 
and  retinal  hemorrhages,  have  been  noted.  The  cornea  is 
often  involved  late  in  the  disease.  Plastic  inflammation 
of  the  iris  and  choroid,  and  purulent  choroiditis  (page  341) 
and  retinitis  (page  362)  leading  to  paeudo-glioma,  are  very 
important  complications.  Ojtf!r  neuritis,  tending  to  con- 
secutive atrophy  (page  391)  if  the  patient  survive,  is  not 


580  CEREBROSPINAL  MENINGITIS. 

rare.  Abnormalities  of  the  pupil  (page  72)  are  common, 
and  palsies  of  the  extra-ocular  muscles  (page  204)  occur. 
Purulent  inflammation  commonly  ends  in  blindness,  and 
plastic  inflammation  of  the  uveal  tract  may  do  the  same. 
Optic  neuritis  may  be  followed  by  recovery,  usually  par- 
tial. Other  conditions  commonly  end  in  recovery.  A 
large  proportion  of  cases  presenting  severe  lesions  of  the 
eye  do  not  survive  the  attack. 

Erysipelas  of  the  eyelids  has  already  been  described 
(page  452).  It  is  only  when  affecting  the  lids  and  ad- 
joining parts  that  it  is  likely  to  involve  the  eye,  unless  it 
causes  meningitis.  If  it  extends  into  the  orbit  it  may 
cause  retinal  thrombosis  (page  376),  optic  neuritis  (page 
384),  or  optic  atrophy  (page  391).  Its  tendency  to  cause 
glaucoma  (page  438)  has  been  frequently  noted,  but  not 
satisfactorily  explained.  It  may  cause  inflammation  of 
the  lacrimal  gland  (page  467)  or  of  the  lacrimal  sac. 

Pyemia,  septicemia,  and  puerperal  fever  are  liable 
to  involve  the  eye,  causing  either  retinal  hemorrhage 
(page  360)  and  thrombosis,  or  purulent  inflammation  of 
the  choroid  (page  341)  or  retina  (page  362),  and  pseudo- 
glioma,  or  panophthalmitis  through  septic  embolism. 

Typhoid  fever  may  be  attended  with  catarrhal  con- 
junctivitis (page  241),  and  is  often  succeeded  by  decided 
weakness  of  accommodation  (page  144).  It  may  be  compli- 
cated by  inflammation  of  the  uveal  tract ;  and  in  rare  cases 
optic  neuritis  and  subsequent  atrophy  occur.  Typhus 
may  cause  conjunctivitis  and  uveal  inflammation.  In  the 
typhoid  state  developing  in  any  acute  disease,  the  cornea 
is  liable  to  suffer  from  exposure  by  imperfect  closure  of 
the  lids,  to  become  dry  and  bazy,  and  later  to  ulcerate. 

Relapsing"  fever'  is  followed  after  some  weeks  by 
uveal  inflammation,  especially  cyclitis  (page  324)  and  cho- 
roiditis  (page  344),  attended  witli  ritrcons  opacity.  It 
may  end  in  recovery,  or  shrinking  of  the  eye  (page  350), 
or  panophthalmitis  (page  341). 

Cholera. — In  this  disease  sinking  of  the  eye  and  con- 
traction of  the  retinal  vessels,  with  a  dark  venous  color 
of  the  arteries,  result  from  the  general  loss  of  fluid,  and 


OCULAR  SYMPTOMS  OF  DISEASE.  581 

the  cornea  is  especially  liable  to  suffer  from  exposure, 
leading  to  keratitis  if  the  patient  survives. 

Yellow  fever  begins  with  marked  conjtiuctival  hyper- 
emia  (page  237)  and  lacrimation.  Subsequently  the 
general  yellow  discoloration  is  added  to  the  redness  of 
the  conjunctiva.  Subconjunctival  hemorrhages  (page  270) 
and  retinal  hemorrhages  (page  360)  may  occur. 

CONDITIONS  OF  THE  SEXUAL  ORGANS. 

Certain  of  the  diseases  of  the  eye  show  a  distinct  pre- 
dilection for  one  sex  rather  than  the  other.  Thus,  spon- 
taneous retinal  hemorrhages  occur  in  young  men,  and 
idiopathic  optic  neuritis  is  more  common  in  women. 

Sexual  excesses  have  seemed  to  cause  optic  atrophy 
in  men,  quite  apart  from  syphilis  or  other  causes. 

Menstruation  exerts  a  marked  influence  on  chronic 
inflammatory  disease,  in  some  women,  or  upon  the  recur- 
rence of  conjunctivitis  or  scleritis.  Disease  of  the  uveal 
tract  with  vitreous  opacities  is  especially  influenced  by 
it.  Arrest  of  menstruation  may  be  followed  by  hemor- 
rhages, either  subconjunctival  or  into  the  vitreous  (page 
429)  or  retina  (page  360),  and  much  hemorrhages  may 
occur  at  recurring  menstrual  epochs.  Profuse  uterine 
hemorrhage  may  cause  amaurosis. 

Pregnancy  may  give  rise  to  albuminuric  retinitis 
(page  365),  which  may  be  so  severe  as  to  justify  prema- 
ture labor  to  prevent  blindness.  When  the  question 
arises,  it  is  hot  merely  a  matter  of  blindness,  since  the 
retinal  lesion  indicates  very  grave  danger  to  the  patient's 
life  and  diminished  chances  of  a  living  healthy  child,  even 
if  born  at  term.  The  prognosis  for  recovery  from  the 
retinal  lesions,  after  termination  of  the  pregnancy,  is 
good  as  compared  with  other  forms  of  albuminuric  retin- 
itis, if  serious  renal  disease  does  not  remain. 

I/actation,  if  too  prolonged,  and  seriously  impairing 
the  mother's  strength,  may  cause  blindness  by  anemia  of 
the  retina  and  subsequent  optic  atrophy.  Slight  abrasions 
of  the  cornea  may  give  rise  to  a  very  painful  ulceration 


582  LACTATION. 

(page  286).  The  patient  may  also  suffer  from 
out  of  proportion  to  her  ametropia,  or  the  amount  of  eye- 
work.  Ocular  disorders  ascribed  to  the  menopause  are 
more  frequently  due  to  failing  accommodation  (page  144). 

DISEASES  OF  THE  NOSE. 

The  intimate  relations  of  the  eyes  with  the  nose  are 
illustrated  by  such  common  reflexes  as  the  provocation 
of  sneezing  by  the  flashing  of  a  bright  light  in  the  eyes, 
or  the  free  lacrimation  produced  by  any  irritation  of  the 
nasal  mucous  membrane. 

Acute  cory^a  is  commonly  attended  with  conjuncti- 
val  hyperemia  and  increased  lacrimation,  which  frequently 
passes  into  an  acute  catarrhal  conjunctivitis  (page  237)  or 
a  blepharitis  (page  449). 

Catarrhal  rhinitis  of  the  form  compared  to  eczema 
of  the  skin,  and  frequently  coexistent  with  eczema,  is  a 
common  cause  of  relapsing  phlyctenular  conjunctivitis 
(page  261)  or  phlyctenular  keratitis  (page  268).  Its  cure 
may  be  essential  to  prevent  further  relapses. 

Hypertrophic  rhinitis  may,  by  pressure,  close  the 
lower  end  of  the  lacrimo-nasal  duct,  causing  lacrimal 
obstruction  (page  465)  with  all  its  consequences.  (Vm- 
tricial  contraction  after  severe  acute  rhinitis  or  atrojihic 
rhinitis  may  do  the  same  thing.  Chronic  inflammations 
within  the  nose  are  liable  to  extend  to  the  lacrimal 
duct  and  sac,  and  produce  obstruction  by  swelling  of  the 
lining  membrane.  Caries  and  necrosis  of  the  adjoining 
bones,  cause  some  of  the  most  obstinate  and  hopeless 
cases  of  lacrimal  obstruction. 

Polypoid  growths  are  probably  a  cause  of  optic 
atrophy.  A  form  of  atrophy  (page  393)  associated  with 
dropping  of  watery  fluid  from  the  nostril,  and  associated 
with  the  presence  of  polypi,  has  been  reported.  The 
damaging  pressure  is  doubtless  exerted  in  the  sphenoidal 
sinuses.  Such  growths  have  also  .seemed  to  cause  stra- 
bismus. 

Active   treatment   of  nasal    disease,    especially    by    the 


OCULAR  SYMPTOMS  OF  DISEASE.  583 

galvano-cautery,  has   caused  temporary   amblyopia   and 
even  optic  neuritis. 
Diseases  of  cavities   accessory  to  the    nose 

(the  frontal,  maxillary,  ethmoid,  and  sphenoid  sinuses) 
cause  caries  or  necrosis  of  the  orbital  walls  (page  470), 
orbital  abscess  (page  468),  orbital  exostosis  (page  476), 
exophthalmos  (page  465),  palsies  of  ocular  muscles  (page 
204),  optic  neuritis  (page  384),  and  optic  atrophy  (page 
391).  Such  effects  are  usually  caused  by  empyema  of 
these  cavities,  but  may  be  due  to  mucocele.  Such  disease 
may  also  cause  headaches,  which,  on  account  of  their 
location,  are  likely  to  be  ascribed  to  eye-strain. 

POISONS. 

The  effects  of  drugs  upon  the  eye  have  been  elsewhere 
set  forth,  under  mydriatics  (page  127)  or  myotics  (page 
129)  and  the  toxic  amblyopias  (page  397).  Mydriatics 
may  produce  decided  visual  hallucinations.  These  are 
also  very  striking  in  poisoning  by  Indian  hemp  and 
the  mescal  button.  Myosis  (page  76)  is  one  of  the 
effects  of  poisoning  by  opium,  chloral,  and  musoarin. 
Paresis  of  the  ocular  muscles  and  squint  with  diplopia 
may  be  produced  by  alcohol,  gelsemium,  and  to  a  less 
extent  by  other  narcotics.  Yellow  vision,  preceded  by 
brief  violet  vision,  is  one  of  the  most  striking  symptoms 
of  poisoning  by  santonin. 

BIBLIOGRAPHY. 

Kelation  of  Diseases  of  the  Eye  to  General  Diseases.     Max  Knies. 

Edited   by   H.    D.  Noyes,  400  pages,  \Vm.  Wood  &  Co.,  New 

York. 
The  Eye  as  an  Aid  in  General  Diagnosis.     E.  H.  Linnell,  248  pages, 

The  Edwards  &  Docker  Co.,  Philadelphia. 
Medical  Ophthalmoscopy.     "W.   R.  Gowers,   225   pages,  J.  and   A. 

Churchill,  London. 
Eye   Symptoms   in    the    Localization   of  Cerebral    Disease.     H.   R. 

Swanzy,  Bowman  Lecture,  1888. 
Unilateral  Retinal  <  lianges  in  Apoplexy.    K.  T.  Williamson,  "Brit. 

Med.  Jour.,"  June  11,  1898. 
Eye  Symptoms  of  Intracranial  Tumors.     G.    E.  de  Schweinitz  and 

W.  V.  Norris,  "University  Medical  Magazine,"  Mar.,  1896. 


584  BIBLIOGRAPHY. 

The  Mimicry  of  Brain  Tumor  by  Chronic  Nephritis.  C.  W.  Burr, 
"  Philadelphia  Medical  Journal,"  Feb.  5,  1898. 

Eve  Disease  After  Injuries  to  the  Spinal  Cord.  Dunbar  Rov, 
"Philadelphia  Medical  Journal,"  Nov.,  12,  1898. 

Ocular  Lesions  of  Acromegaly.  Strzeminski,  "  Ophthalmic  Review," 
Mar.,  1897. 

Ocular  Lesions  from  Secretory  and  Excretory  Disorders.  J.  B. 
Lawford,  "  System  of  Diseases  of  the  Eye,"  vol.  iv. 

Ocular  Lesions  Due  to  Disorders  of  Circulation.  O.  Haab,  "  Sys- 
tem of  Diseases  of  the  Eye." 

Ophthalmoscopic  Evidence  of  General  Arterial  Disease.  Marcus 
Gunn,  "  Trans.  Ophthal.  Soc.  of  the  United  Kingdom,"  March, 
1898. 

Prognostic  Significance  of  Albuminuric  Retinitis.  E.  O.  Belt, 
"Trans.  Sect,  on  Ophthalmol.,  Amer.  Med.  Assoc.,"  1895. 

Retinal  Hemorrhages  After  Middle  Life.  Hasket  Derby,  "  Trans. 
Massachusetts  Med.  Soc.,"  1897. 

Ocular  and  Nervous  Affections  in  Diabetes.  J.  Anderson,  "Oph- 
thalmic Review,"  Feb.  and  Mar.,  1889. 

Changes  of  Refraction  with  Variations  of  Sugar  in  the  Urine.  S.  D. 
Risley,  "Ophthalmic  Record,"  July,  1897. 

The  Gouty  and  Rheumatic  Diatheses  with  Relation  to  Diseases  of  the 
Eye.  "Symposium,  Trans.  Cong.  Amer.  Physicians  and  Sur- 
geons," 1897. 

Ocular  Manifestations  of  Leprosy.  Jeanselme  and  Morax,  "  Oph- 
thalmic Review,"  Dec.,  1898. 

Sequels  of  Influenza.  C.  S.  Bull,  "Annals  of  Ophthalmology," 
April,  1895. 

Temporary  Blindness  During  Lactation.  E.  Nettleship,  "  Roy. 
London  Ophthal.  IIosp.  Rep.,"  vol.  xiii,  pt.  ii. 


INDEX. 


ABADIE,  Ch.,  441 
Abbreviations,  23,  434 
Abduction,  193,  231 
Aberration,  186,  310,  410 
Abney,  W.  de  W.,  55 
Abrasion  of  cornea,  299,  487 
Abscess  of  cornea,  278,  290,  291,  547 

of  lids,  450 

of  orbit,  468 
Abscission,  548 
Absolute  hyperopia,  149 

scotoma,  39 

Accommodation,  124,  132,  149,  152, 
341 

amplitude  of,  126,  146 

spasm  of,  149 

weakness  of,  41,  144,  164,  332,  341 
Acetauilid,  402,  511 
Aching,  52,  53,  239 
Achromatopsia.    See  Color  Blindness. 
Actual  cautery,  283,  547 
Acuteness  of  vision,  18,  20,  21,  25, 

569 

Adaptation  to  glasses,  189 
Adduction,  193.  231 
Adenoma,  353 

Adherent  leucoma,  70,  301,  304,  446 
Adhesion  of  lids,  66,  238,  455 
Adjoining  cavities,  476,  583 
Adrenal  extract,  520,  529 
Advancement,    muscular,  214,  222, 

234,  544 
After-treatment  of  cataract,  556 

of  enucleation,583 
Age  of  patient,  18,  21,  26,  146,  221 
Air-bubbles  in  vitreous,  497 
Akromegaly,  570 
Albinism,  88,  355 
Albumiimric  retinitis,  91,  365,  573, 

578,  581 

Alcohol  amblyopia,  399 
Aldrich,  C.  .1.',  2:',(i 
Allen,  Harrison,  295 
Alt,  A.,  356 
Altitudiual  hemianopsia,  37 


Alum.  512 
Amaurosis,  402,  573 
Amaurotic  family  idiocy,  374 
Amblyopia,  198,  397,  402 

central,  40,  397 

congenital,  403 

ex  abusa,  397,  399 

ex  anopsia,  198 

from  acetauilid,  402 

from  alcohol,  399 

from  carbon  bisulphid,  400 

from  iodoform,  400 

from  nitrobenzol,  400 

from  quinin,  401 

from  tobacco,  397 

hysterical,  403 

simulated,  403 

toxic,  397 

uremic,  365,  573 

with  squint,  198 
Ametropia,  19,  124,  134,  267,  411 
Amman,  E.,  383 
Amplitude  of  accommodation,  126, 

146 

Amyloid  degeneration  of  conjunc- 
tiva, 269 

Anchyloblepharon,  458 
Anderson,  J.,  584 
Andrews.  J.  A.,  356 
Anemia,  359,  363,  383,  572 

of  optic  disk,  96,  384 

of  retina,  93,  359,  577 
Anesthesia  of  cornea,  54,  287,  436 
Anesthetics,  514 
Aneurism,  473,  567,  573 
Angioiua,  271,  460,  474 
Angioid  streaks  in  retina,  374 
Angle  of  anterior  chamber,  439 

of  deviation,  111 

of  vision,  25 
Aniline  dyes,  67,  510 
Anisometropia,  188 
Auiridia,  354 
Annular  synecliia,  327 
Anomalies  of  iris  and  choroid.  353 

585 


58G 


INDEX. 


Anomalies  of  optic  disk,  98 

of  pigmentation,  356 

of  refraction,    124 

of  retina,  381 
Anoptithalmos,  475 
Anterior  chamber,  407,  425,  547 
foreign  body  in,  495 

sclerotomy,  441,  549 

staphyloma,  305,  548 

symblepharon.  270 

synechia,  71,  293,  301,  304 
Antimetropia,  188 
Antipathy  to  single  vision,  220 
Antiseptics,  507,  523 
Antitoxin,  diphtheria,  252 
Antrim),  maxillary,  477 
Apex  of  prism,  106 
Aphakia,  407,  417,  426 
Apoplexy,  567,  568 
Apparent  movement,  137 

squint,  199,  219 
Application  of  remedies,  500 
Applications    to    conjunctiva,   504, 

509,  520 

Aqueous  humor,  407 
Arcus  senilis,  70,  301 
Argyll-Robertson  pupil,  74,  569 
Argyria,  273 
Aristol,  511 
Arsenic,  511 
Arterial  pulsation,  437 
Artificial  eye,  564 

leech,  529 

Asepsis,  246,  505,  507,   523 
Associated  movements,  205 
Assorted  light,  104,  121 
Asthenopia,  144,  151,  157,  174,  206, 

227,  435,  578,  582 
Astigmatism,  46,  167,  169 

changes  in,  186 

diagnosis,  174,  176,  178,  180 

irregular,  167 

regular,  167,  169     • 

treatment,  184,  188 

varieties  of,  169,  172 
Astigmatic  lens,  184 
Astigmia,  167 
Astringents,  506,  511 
Atresia  of  punctum,  463 
Atrophy  of  eyeball,  350 

of  iris,  329 

of  optic  nerve,  98,  391,  398,  567 

of  retina,  361 
Atropin,  127,  238,  277,  289,  296,  322, 

516,  517,  518,  519 
Atwool,  W.  T.,  383 


Auramin,  510 

Available  accommodation,  146 
Axenfeld,  T.,  243,  313 
Axial  hyperopia,  147,  149 

myopia,  155,  158 

optic  neuritis,  391,  397,  574 
Axis  of  cylindrical  lens,  168 
Ay  res,  S.  C.,  478,  566 

BACH,  L.,  522 

Bacteria,  67,  238,  242,  281 

Bacteriologic  examination,  67,  2  lit. 

242,  245,  252 
Baker,  A.  K.,  314,  431 
Balance  of  muscles,  20,  24,  192 
Ballooning  of  iris,  328 
Band  of  light  in  pupil,  180 

opacity  of  cornea,  302 
Bandages,  528 
Barkan,  A.,  500 
Barrett,  J.  B.,  383 
Basedow's  disease,  472,  534,  570 
Base  of  prism.  106 
Bates,  W.  H.,  313,  522 
Batten,  R.  IX,  190 
Beach,  G.  W.,  273 
Beer,  Th.,  143 
Belt,  E.  O.,  584 
Bernstein,  E.  J.,  522 
Berry,  G.  A..  55 
Bettman,  B.,  431 

Bibliography,  54,  77,  103,  121,  143, 
190,  237,  273,  313,  356,  382, 
406,  431,  477,  500,  522,  565, 

.      583 
Bident,  425 

Bichlorid  of  mercury,  509 
Biconcave  lens,  114 
Biconvex  lens,  115 
Biniodid  of  mercury,  509 
Binasal  hemianopsia,  .'57 
Binocular  co-ordination,  198 

diplopia,  46,  195,  197,  219,  220 

fusion,  195,  206 

magnifier,  68 

vision,  33,  157,  164,  191,  198,  213, 

220 

Bisulphid  of  carbon,  400 
Bitemporal  hrmianopsia,  37 
Black  cataract.  412 
Black.  G.  M.,  274 
Blackboard  fields,  35 
I'.l.-.'ding.  323.  529 
Bleiniorrhc  a.  243,  256 
Blepharitis,  448 

ciliaris,  449 


INDEX. 


587 


Blepharitis,  marginal,  449,  575 
Blepharophimosis,  458 
Blepharospasm,  56,  457 
Blindness,  32,  74,  218,  249,  340,  344, 

442,  479,  498 
Blind  spot,  33 

Blood  in  anterior  chamber,  408 
Blood-vessels  in  vitreous,  430 
Blue  glass,  227 

vision,  48 

Blurring  of  sight,  147,  151 
Boric  acid,  510,  511,  514 
Boroglycerid,  513 
Bossaliuo,  D.,  522 
Bowman,  Wm.,  434 
Brachymetropia,  155 
Bmiley,  W.  A.,  356 
Brain  abscess,  387,  567 

disease,  389,  567 

tumor,  387,  567 
Braunschweig,  P.,  406 
Brief  recurring  episcleritis,  243 
Bright's  disease,  367,  573 
Brossage,  260 
Bruise  of  lids,  479 

of  eyeball,  481,  483 
Bull,  C.  S.,  236,  382,  383, 432,  478, 584 
Bull,  G.  J.,  191 
Buller,  F.,  236,  249,  357,  478 
Buller's  shield,  249,  529 
Bullous  keratitis,  286 
Buphthalmos,  446 
Burnham,  G.  H.,  522 
Burnett,   S.   M.,  55,   121,  190,  293, 

313 

Burning  pain,  49,  239 
Burns,  269,  272,  311,  462 
Burr,  C.  W.,  584 
Buzzard,  Wm.,  406 

CALLAN,  P.  A.,  500 
Calomel,  303,  520 
Canaliculus,  disease  of,  464,  540 
Canal  of  Schlemin,  433,  443 
Canthoplasty,  261,  531 
Canthotomy,  248,  261,  531 
Capsule  of  lens,  77.  422,  553,  554 
Capsulotomy,  423,  559 
Carcinoma,  331,  353 
Card  records,  22 
Caries,  orbital,  470 

spinal,  569 

Carotid,  rupture  of,  473 
Carpenter,  J.  T.,  236.  357 
Carrow,  Fleming,  432 
Caruncle,  diseases  of,  273 


Case,  history,  17 

records,  20,  22,  28 
Caspar,  L.,  383 
Cassareep,  284 
Cataphoria,  226 
Cataract,  160,  407.  408,  553,  569 

anterior  polar,  281,  419 

black,  412 

capsular,  422 

central,  421 

choroidal,  412 

complicated,  412,  555 

congenital,  419 

cortical,  412 

diabetic,  414 

diagnosis  of,  413,  421,  423,  444 

extraction,  417,  418,  553 

fusiform,  421 

glasses,  417 

hard,  409 

hypermature,  411 

incipient,  411,  415 

juvenile,  418 

knives,  553 

lamellar,  420 

mature,  411,  413,  416 

Morgagnian,  412 

nuclear,  412,  418 

operations,  553 

partial,  419 

perinuclear,  420 

ripening  operations,  416 

secondary,  418,  422 

senile,  409 

soft,  418 

swollen,  411 

traumatic,  412,  482,  489,  496 

treatment  of,  415,  421,  423 

vision  after  extraction  of,  418 

zouular,  420 
Catarrh   of    conjunctiva,   237,  253, 

255,  256,  575 

Caterpillar  hairs,  243,  493 
Caustics,  272,  503,  506,  511 
Cautery,  283,  547 
Cavernous  angioma,  460 

sinus,  thrombosis  of,  469 
Cavities  adjoining  orbit,  476,  583 
Cellulitis,  orbital,  343,  578 
Centrad, 111 
Central  cataract,  421 

scotoma,  40,  397,  569,  574 
Centers  for  vision,  32.  37,  46 
Cerebral  disease,  374,  389,  567 
(Vrebrospinal   meningitis,  343,  579 
Chalazion,  459,  537 


588 


INDEX. 


Chancre,  268,  575 
Chandler,  H.  B.,  284 
Chemosis,  65,  239,  244,  342 
Chicken-pox,  579 
Children,  applications  to,  507 
Chisolm,  J.  J.,  432 
Chlorid  of  mercury,  509 

of  zinc,  511,  513 
Chloroform,  514 
Chloroma,  476 
Choked  disk,  385 
Cholera,  580 

Cholesterin  crystals,  83,  408,  429 
Chorea,  227,  570 
Chorioretinitis,  369,  576 
Choroid,  87,  99,  341,  567 
Choroidal   atrophy,    100,   101,    160, 
174,  344,  347 

cataract,  412 

coloboma,  348 

crescent,  86 

detachment,  349 

exudate,  101,  160,  174 

hemorrhage,  349 

inflammation.     See  Choroiditis. 

injuries,  483,  496 

ossification,  349 

pigment,  100 

ring,  85,  100 

rupture,  102,  484 

sarcoma,  350 

tuberculosis,  352,  575 

vessels,  87 
Choroiditis,  anterior,  347 

central,  346 

diffuse,  347 

disseminated,  346,  576 

localized,  346 

myopic,  160,  346 

plastic,  344 

purulent,  341,  579 

senile,  347 
Chronic  conjunctivitis,  253 

glaucoma,  435,  443 

opacities  of  cornea,  301 
Cilia,  56,  529 

Ciliary  body,  gumma  of,  330 
sarcoma  of,  331 
wounds  of,  488 

muscle,  124,  129,  332 
Cilioretinal  vessels,  86 
Circulatory  disorders,  365,  374,  572 
Circulation  of  blood  in  retina,  48 
Claiborne,  J.  H.,  357 
Cleansing  the  eye,  246,  505,  507 
Closure  of  punctum,  463 


Cocain,  128,  322,  439,  515,  516,  518, 

519 

Cold  applications,  504 
Coleman,  W.  F.,  432 
Colloid  masses,  349,  393 
Collins.  E.  T.,  314,  357,  383,  478 
Collyria,  504,  507,  511,  515 
Coloboma  of  choroid,  348,  354 

of  iris,  354.  552 

of  lens,  425 

of  optic  nerve,  99,  397 
Color  blindness,  48,  403 

fields,  47 

of  iris,  71 

of  fundus,  87 

perception,  47 

scotoma,  40.  397 

tests,  40 

vision,  47 
Coma,  568 

Combined  extraction,  417 
Comitant  squint,  200,  203,  214,  223, 

225 

Commotio  retinae,  483 
Complementary  colors,  49 
Complicated  cataract,  412,  555 
Complications  of  euucleation,  563 
Compound  astigmatism,  172,  173 
Concave  lens,  113,  114,  163,  167 

mirror,  137 
Concomitant  squint,  200,  203,  214, 

223,  225 

Concretions  in  conjunctiva,  271 
Confusion  colors,  49 
Congenital  amblyopia.  403 

color  blindness,  49,  403 

colobomas,  99,  348,  354,  425 

opacity  of  cornea,  296,  307,  576 

squint,  198 

Conical  cornea,  187,  309,  547 
Conjunctiva.  60,  237 

foreign  bodies  in,  492 

wounds  of,  487 

Conjunct! val  applications.  504,  506. 
507,  509 

catarrh.     See  Conjunctivitis. 

discharge,  66.  238,  243,  251,  254, 
257 

hemorrhage,  239 

hype  rein  ia,  60,  237,  577 

operations,  537 

swelling,  65,  239,  244,  251,  342 
Conjunctivitis,  catarrhal,  237,  253, 
255,  261,  575,  577 

contagious,  241,  243 

croupous,  250 


INDEX. 


589 


Conjunctivitis,  diagnosis  of,  60,  65, 
240,  242,  245,  251,  254,  259, 
263,  320 

diphtheritic,  250 

diplobacillus,  242 

exanthematous,  241 

follicular,  256 

granular,  256 

lacrimal,  465 

lymphatic,  261 

membranous,  253 

Parinaud's,  255 

phlyctenular,  261,  575 

prophylaxis  of,  248 

purulent,  243,  576 

strumous,  261 

treatment  of,  240,  242,  243,  246, 
252,  254,  256,  259,  263,  504, 
509 

vernal,  255 
Connor,  L.,  236 
Consensual  reaction,  74 
Contents,  table  of,  5 
Contraction  of  pupil,  75,  316 

of  visual  field,  41,  392,  397 
Contusions,  479,  481,  483 
Conus,  102,  161 

Convergence,  57,  193,  205,  218,  226 
Convergent  squint,  208,  210,  222 
Convex  lens,  113,  115,  167 
Convulsions,  568 
Coover,  D.  H.,  566 
Copper  sulphate,  511 
Corectopia,  353 
Corelysis,  327,  552 
Cornea,  applications  to,  504,  547 

diseases  of,  275 

foreign  bodies  in,  493,  545 

transplantation  of,  304 
Corneal  abrasions,  299 

abscess,  278,  290,  291,  547 

astigmatism,  172,  180 

blood-vessels,  275,  288,  292,  294, 
295 

ectasia,  309 

fistula,  447 

gumma,  293 

infiltration,  294 

inflammation.     See  Keratitis. 

macula.  301 

nebula,  301 

opacities,  70,  275,  277,  296,  300, 
302,  502 

operations,  545 

phlyctenule,  288 

pigment,  303 


Corueal  reflex,  70,  81,  83,  88 
repair,  276 

section,  284,  546,  553,  556 
staphyloma,  305 
surface,  17,  18 
ulcer,  244,  276,  546,  578 
wounds,  487 

Correcting  lenses,  146, 153, 163,  166, 
170,  185,  221,  232,  348,  415, 
417,  449 

Corresponding  points,  194 
Corrosive  sublimate,  509,  521 
Cortical  cataract,  412 
Coryza,  581 
Counting  fingers,  29 
Cover-test  for  squint,  199,  219,  227 
Crater-like  pupil,  328 
Crede  method,  249 
Creeping  ulcer,  278 
Cross,  F.  E.,  383 
Crossed  blindness,  32 
cylinder,  184 
diplopia,  197,  209,  212 
Crown  glass,  111 
Croupous  conjunctivitis,  66,  250 
Cryptoglioma,  381 
Crystalline  lens,  77,  124 
aberration  of,  187 
absorption  of,  490 
astigmatism  of,  172 
changes  in,  124,  125,  408,  440. 
diseases  of,  408 
dislocation  of,  424,  439,  443,  480, 

482 

injuries  of,  480,  482,  489,  496 
opacity  of.     See  Cataract. 
removal  of,  165,  417,  553,  560 
Culver,  C.  M.,  143 
Culture-tests,  67 

Cupping  of  optic  disk,  8(5,  97,  437 
Curetting  cornea,  283,  300.  546 
Curvature  hyperopia,  147,  149 

myopia,  155,  158 
Cutler,  C.  W.,  121 
Cutting  lacrimal  stricture,  542 
Cyanid  of  mercury,  509 
Cyclitis,  320,324,326,  334,  574,  576 
Cyclophoria.     See  Rotary  Deviation. 
Cycloplegia,  127,  332,  48i 
Cycloplegics,  127,  222 
Cylindrical  lenses,  167,  183,  185 
i  Cyst,  conjunctival,  271 
of  iris,  332 

of  lacrimal  gland,  468 
of  lid,  460,  475 
Cysticercus,  271,  380,  430,  460 


590 


INDEX. 


Cystoid  cicatrix,  447 
Cystotome,  554 

DACRYOADENITIS,  467 
Dacryocystitis,  466 
Dacryolith,  464 
Dacryops,  468 
Dalrymple's  sign,  472 
Darier,  A.,  274 
Dark  glasses,  348 

room,  349,  501 
Daturin,  127 

Davidson,  J.  Mackenzie,  500 
Davis,  A.  E.,  103 
Day-blindness,  359 
De  Beck,  D.,  432,  477 
Decentering  of  lenses,  232 
Decussation  at  chiasm,  32 
Degeneration  of  iris,  329 
Degree  of  squint,  192 
Degree  of  prisms,  111 
Delirium,  568 
Dendritic  keratitis,  286 
Dennett,  W.  S.,  Ill,  121, 
Depth  of  anterior  chamber,  407 
Derby,  H.,  284,  584 
Dermatitis,  451 

Dermoids,  266,  271,  311,  460,  474 
Detachment  of  choroid,  349 

of  retina,  166,  352,  377,  573 

of  vitreous,  430 
Deviating  eye,  192,  207,  214 
Deviation  of  eye,  192,  207,  227 

by  prisms,  111 
Diabetes,  314,  359,  368,  574 
Diagnosis,  19 
Diagrams,  21 
Diathetic  diseases,  574 
Diet,  263,  297,  312 
Dilatation  of  pupil,  75,  76,  440 
Diminished  tension  of  eyeball,  447 
Diopter,  117 
Dioptric  media,  105 
Dioptric  system  of  numbering,  117 
Dioptrics,  104 
Diphtheria  bacillus,  251,  252,  253, 

281 

Diphtheritic  conjunctivitis,  66,250, 
578 

paralysis,  212,  214,  333,  578 
Diplobacillus,  242,  281 
Diplococcus,  238,  256 
Diplopia,  46,  194,  195,  197,  202,  206, 

207,  214,  219,  404,  424 
Direct  massage  of  lens,  416 
Direct  method,  131 


Discission  for  cataract,  558 
Discoloration  of  conjunctiva,  273 
Disk.    See  Optic  Disk. 
Disks,  gelatin,  507,  508 
Dislocation  of  eyeball,  480 

of  lacrimal  gland,  468 

of  lens,  424,  439,  445,  480,  482 
Dispersion  of  light,  110 
Displacement  of  punctum,  464 
Distention  of  eyeball,  161,  432,446 
Distich  iasis,  454,  529,  530 
Distortion  of  images,  45 
Divergent  rays,  104 

squint,  157,  209,  212,  221 
Division  of  upper  lid,  248,  533 

of  tarsal  ligament,  533 
Dodd,  O.,  382,  406 
Donders,  F.  C.,  143 
Double  concave  lens,  115 

convex  lens,  114 

images,  208 

prism,  229 

vision.     See  Diplopia. 
Douche,  505 
Dragged  disk,  162 
Dressings,  527 
Drug  eruptions,  451 
Drusen,  349,  393 
Duane,  A.,  235 
Duboisin,  127,  517,  518 
Dunn,  John,  478 
Dusting  powders,  511 
Dyer,  E.,  236 
Dyslexia,  571 

ECCHYMOSIS,  conjunctival,  270,  498 

of  lids,  479,  498 
Ectopia  lent  is,  424 
Ectropion,  456,  534 

organic,  456 

paralytic,  456,  534 

uvese,  331,  353 
Eczema,  261,  451 
Edema  of  conjunctiva,  270 

of  lids,  64,  459,  579 

of  retina,  362,  573 
Edge  of  prism,  110 
Educative  treatment  of  squint.  223 
Electricity,  213,  304 
Electric-light  retinitis,  371 
Electrolysis,  267,  530,  537 
Electro-magnet,  498 
Elevator,  lid,  526 
Ellett,  E.  ('..  -10(5 

Embolism  of  retinal  artery,  374, 570, 
574 


INDEX. 


591 


Emmetropia,  123,  139 
Emphysema,  64,  270,  459,  479 
Empyema,    of    adjoining   cavities, 

476,  477 
Encanthus,  273 
Encephalocele,  475 
Enophthalmos,  471,  480 
Entoptic  method,  42,  44 
Entropion,  organic,  455,  530 

spasmodic,  455,  530 
Euucleation  of  the  eye,  338,  341, 

343,  561 

Epicanthus,  458 
Epidermoid  pearl  of  iris,  332 
Epilation-forceps,  530 
Epilepsy,  227,  569 
Epiphora,  462,  569 
Episcleritis,  243,  311,  574 
Epithelial  grafting,  534,  538 
Epithelioma,  271,  461 
Equivalent  lenses,  116 
Erect  image,  131,  138 
Errors  of  refraction,  124,  144 
Erysipelas,  343,  441,  452,  580 
Erythropsia,  48 
Eserin,  129,  442,  519 
Eskridge,  J.  T.,  406 
Esophoria,  226 
Ether,  514 

Ethmoidal  disease,  389,  477 
Ethylate  of  sodium,  460 
Eucain,  515 
Euphthalmin,  129,  516 
Eve,  383 

Eversion  of  lids,  57 
Evisceration  of  the  globe,  338,  341, 

564 

Ewing,  E.  A.,  313 
Examination,  bacteriologic,  67 

entoptic,  42,  44 

microscopic,  67 

of  case,  17 

of  conjunctiva,  60 

of  eye,  18,  568 

of  lids,  56 

ophthalmoscopic,  18,  80,  84,  131, 

142,  176,  496 

Exanthematous  conjunctivitis,  241 
Excision   of  cervical  sympathetic, 
441 

of  anterior  staphyloma,  308,  548 

of  chalazion,  4(>0,  537 

of  pterygium,  2(i<>.  537 

of  roots  of  lashes.  531 
Exciting  eye.  .'$:>! 
Exclusion  of  light,  501 


Exclusion  of  pupil,  327 

Exercises,  gymnastic,  213,  223,  233 

Exophoria,  226 

Exophthalmic  goiter,  472,  534,  570 

Exophthalmos,   65,   469,    471,   472, 

480 

Exostosis,  476 

Expression  for  trachoma,  259,  539 
External  rectus,  208,  210 
Extirpation  of   lacrimal  sac,   460, 

542 
Extract  of   suprarenal  body,  520, 

529 

Extraction  of  cataract,  417,  553,  557 
of  foreign   body,   493,   495,   498, 

545,  560 

Eyeball,  dislocation  of,  480 
operations  on,  560 
rupture  of,  480 
Eyebrows,  454 
Eye-douche,  505 
Eye-glasses,  189 
Eye-ground,  84 
Eyelashes,  56 
Eyre,  J.  H.  W.,  274 
Eye-shade,  528 
Eye-strain,   17,    145,   150,  157,  160, 

174,   227,  253,    314,  324,  388, 

440,  449,  569,  570,  572 
Eye-symptoms  of  general  diseases, 

566 

FACIAL  paralysis,  457 
Facultative  hyperopia,  149 
Failure  of  accommodation,  147, 151 
False  image,  197,  207 

scotoma,  39 
Family  history,  18 
Far-point,  148 

sight,  147 
Fatty  degeneration   in  retina,  91, 

359 

Fibroma,  271,  460,  476 
Fibrosarcoma,  476 
Field  of  vision,  23,  33,  47,  373,  377, 
391,  437,  443,  498,  567,  569,  571 

for  colors.  47.  392,  397 
Filamentous  keratitis,  287 
Filaria,  271,  430 
Filix  mas  amblyopia,  402 
Finger-tests,  29,  36 
Finley,  C.  E.,  478 
Fisher,  E.  C.,  431 
Fisher,  J.  H.,  382 
Fissures  of  lids,  263.  264,  289,  451 
Fistula,  lacrimal,  467 


592 


INDEX. 


Fistula  of  lid,  468 
Five-minute  angle,  27 
Fixing  eye,  192,  207 
Fixation  for  operation,  526 

point,  192 
Flame-shaped     hemorrhages,      91, 

360 

Flashes  of  light,  45,  345 
Flint  glass,  111 
Fluid  vitreous,  428 
Fluorescin,  494,  520 
Focal  distance,  116 

illumination,  68 

lines  and  interval,  170,  173 
Focus,  113 
Focussed  light,  104 
Follicular  conjunctivitis,  256 
Fomentations,  503 
Forceps,  526,  527, 529,  530,  550 
Foreign  body,  51,  265,  271 

in  anterior  chamber,  495 

in  choroid,  496 

in  conjunctiva,  492 

in  cornea,  493,  545 

in  iris,  495 

in  lens,  496 

in  lids  and  orbit,  492 

in  retina,  496 

in  sclera,  495 

in  vitreous,  496,  560 

sensation  of  a,  53,  239 
Formaldehyd,  508 
Fovea,  89 

Fox,  L.  Webster,  566 
Fracture  involving  orbit,  479 
Friedenwald,  H.,  382 
Frontal  sinus,  476 
Frost,  W.  A.,  103 
Frothingham,  G.  E.,  432 
Fryer,  B.  E.,  432 
Fuchs,  E.,  243,  274,  313 
Fukala,  190 
Full  correction,  153 
Fundus  reflex,  81.  84 
Fusiform  cataract,  421 
Fusion  binocular,  224. 

tubes,  220 

GALVANISM,  466 
Galvano-cautery,  283,  547 
<  Jiin-rrene  of  lids,  453 
Gelatin  disks,  507,  518 
General  anesthesia,  514 
General  diseases,  19,  157,  566 

rest,  501 
Gifford,  H.,  243,  273,  274,  313,  406 


Glaucoma,  407, 418, 434, 569,  574, 576 

absolute,  436 

acute,  435 

chronic,  435,  443 

cup,  98,  437,  443 

diagnosis  of,  440,  444 

fulminant,  436 

hemorrhagic,  444 

incipient,  435 

inflammatory,  435 

iridcctomy,  441,  551 

malignant,  443 

post-iritic,  445 

primary,  435,  443 

secondary,  444 

simple,  443 

treatment  of,  441,  444,  502,  551 

with  exacerbations,  435 
Glioma  or  gliosarcoma  of   retina, 

352,  380,  445 
Glycerol  of  tannin,  512 
Goiter,  exophthalmic,  534,  570 
Golovine,  478 
Gonococcus,  243,  245 
Gonorrheal  conjunctivitis,  243,245, 
282,576 

iritis,  319,  576 
Gould,  Geo.  M..  236,  257 
Gout,  312,  368,  440,  574 
Gowers,  W.  E.,  32,  55,  103,  583 
Gradle,  H.,  236,  274.  313 
Graduation  of  trial  frames,  168 
Graefe's  knife,  553 

sign,  472 

test,  229 

Grafts,  epithelial,  535,  538 
Gram  method,  67 
Grandclement,  356 
Granular  conjunctivitis,  256 
Granulated  lids,  244,  254.  256 
Grattage,  260 
Graves's  disease,  472,  570 
Green,  John,  190,  191,  313 
Griffith,  A.  H.,  357 
Griffith,  J.,  478 
Grippe,  578 
Ground  glass,  214 
Growth  of  lens,  440 
Gruber,  R.,  313 
Gruening,  E.,  478 
Grut,  E.  Hansen,  236 
Gumma  of  cornea,  293 

of  iris  and  ciliary  body,  330 
Gunn,  Marcus,  584 
Gygax,  522 
Gymnastic  exercises,  213,  223 


INDEX. 


593 


HAAB,  O,  77,  103,  584 
Haab's  magnet,  561 
Hallucinations,  583 
Halo  atrophy,  438 
symptom,  435 

Hansell,  H.  F.,  235,  236,  357 
Hard  cataract,  409 
Harlan,  G.  C.,  77,  190,  314,  432,  477, 

499 

Harlan,  Herbert,  566 
Harlan's  test,  404 
Harris,  W.,  55 
Hartridge,  G.,  143 
Hay,  G.,  236 
Haziness  of  retina,  90 
Headache,  52,  53,  151,  160,  174,  205, 

227,  567 

Heart  disease,  572 
Heat,  248,  502,  507 
Helmholtz,  H.,  124 
Hemianopsia,  34,  36,  42,  74,  403 
Hemichroniatopsia,  38,  48 
Hemiopia    and    hemianopia.      See 

Hemianopsia. 
Hemorrhage,  conjunctival,  239 

choroidal,  349 

following     cataract     extraction, 
566 

in  anterior  chamber,  408 

into  vitreous,  429,  482,  497 

retinal,  90,  360 

Hemostatics,  503,  520,  529,  556 
Henry,  K.  W.,  54 
Henschen,  S.  E.,  54,  77 
Hereditary  optic  atrophy,  393 

syphilis,  295,  576 
Herpes  of  cornea,  286,  287,  292 

zoster,  452 

Hess,  C.,  124,  143,  314 
Heterochromia,  353 
Heterophoria,  204.  225,  226,  231 
Hinshelwood,  .1.,  190,  566 
Hippus,  73,  332 
Hirschberg,  J.,  431 
Hirschberg's  magnet,  560 
History  of  case,  17,  18 
Hjort,X  432 

Il'olden,  W.  A.,  281,  357,  406 
Holmes,  C.  R.,  478 
Holmgren  test,  49 
Holocain,  2H1.  .">1."> 
Holt,  E.  E.,  500 

Homatropin,  127,  128,  516,  517,  519 
Homonymous    diplopia,    197,    208, 
209,  210 

hemianopsia,  36 

38 


Hordeolum,  450 

Hornlike  growths,  453 

Horopeter,  194 

Horstmann,  C.,  383 

Hot  applications,  502,  503,  529 

Hotz ,  F.  C.,  175,  176,  357,  382,  531, 

566 

Howe,  Lucien,  77,  274 
Hubbell,  A.  A.,  499 
Hutchinson,    Jonathan,    292,    295, 

432 

Hutchinson  teeth,  295 
Hyaline  bodies,  349,  393 
Hyalitis,  429 
Hyaloid  artery,  431 
Hydatids,  430 
Hydraulic  curetting,  283 
Hydrogen  dioxid,  508,  529 
Hydrophthalmos,  446 
Hyoscyamin,  127,  517,  518 
Hyperemia  of  conjunctiva,  60,  237, 
261 

of  glaucoma,  63 

of  iris,  71,  315 

of  optic  disk,  93,  383 

of  retina,  92,  358 

of  sclera,  63 

pericorneal,  61,  315,  324 
Hyperesthesia  of  the  retina,  358 
Hypermature  cataract,  411 
Hypermetropia,  147 
Hyperopia,  123,  131,  139,  147,  221 

absolute,  149 

axial,  147 

facultative,  149 

latent,  149 

manifest,  149 

of  curvature,  147 

total,  149 

Hyperopic  astigmatism,  173 
Hyperostosis,  476 
Hyperphoria,  226 

Hypertrophy  of  conjunctiva,   244, 
245 

of  lids,  475 
Hyphemia,  408 
Hypopyon,  290,  407 
Hysterical  amblyopia,  403,  571 

squint,  234,  572 

ILLUMINATION,  focal,  68,  525 

of  tests,  29 

Images,  true  and  false,  196,  207 
Impairment  of  vision,  25,    30,   41, 

147,   151,    158,  173,  318,  357, 

391,  409,  436 


594 


INDEX. 


Implantation  of  artificial  vitreous, 

565 
Inch  system  of  numbering  lenses, 

116 
Incipient  cataract,  411 

glaucoma,  435 
Incision,  iutermargiiial,  530 
of  chalazion,  537 
of  cornea,  284,  344,  546,  553 
Inconstant  impairment  of  vision, 

41 

Index  of  refraction,  104,  110 
Indirect  massage  of  lens,  416 
Indirect  method,  131,  142 
Inequality  of  pupils,  75 
Infantile     cerebral     degeneration, 

374 

Infectious  diseases,  575,  577 
Inferior  oblique,  209,  211 

rectus,  209,  211 
Infiltration-anesthesia,  515 
Influenza,  578 
Ingrowing  lashes,  455 
Inherited  syphilis,  295,  576 
Injections,  subconjunctival,  507 
Injuries  of  ciliary  body,  481 
of  choroid,  483,  496 
of  conjunctiva,  487,  492 
of  cornea,  487,  493 
of  eyeball,  480 
of  iris,  481,  488,  495 
of  lens,  480,  482,  489 
of  lids,  479,  492 
of  orbit,  479,  492 
of  retina,  483.  496 
of  vitreous,  491,  496 
Inoculation  for  pannus,  300 
Insanity,  571 

Inspection  of  the  eye,  17,  71 
Instillations,  504,  515,  520 
Instruments,  524,  526 
Insufficiencies,  muscular,  203,  225, 

231 

Intention  nystagmus,  234 
Intermargiual  incision,  530 
Internal  rectus,  209,  211 
Intoxication,  mydriatic,  128 
Intracranial  disease,  5(i7 
lutra-ocular  currents,  432,  439 
tension,  432,  434 
tumors,  350,  352,  380,  445 
Inverted  image,  131,  135,  138,  142 
lodid  of  potassium,  303,  521 
lodin,  513 
lodoform,  511,  513 
amblyopia,  400 


Iridectoiny,  304,  307,  327,  339,  421, 
549,  557 

for  glaucoma,  441,  442,  447,  551 

optical,  304,  307,  339,  421,  551 

preliminary,  416.  549 

with  cataract  extraction,  417,  557 
Iridencleisis,  553 
Irideremia,  354 
Iridochoroiditis,  341 
Iridocyclitis,  324,  334, 447 
Iridocystectomy,  552 
Iridodesis,  553 
Iridodialysis,  481 
Iridodonesis,  332,  423 
Iridoplegia,  332,  481 
Iridotomy,  552 
Iris,  17,  71,  314 

bom  be,  328 

cyst,  332 

diseases  of  314 

gumma  of,  320 

foreign  body  in,  495 

injuries  of,  481,  488 

prolapse  of,  284,  480,  488,  556 

sarcoma  of,  331 

trembling  of,  332,  423 

tuberculosis  of,  330 

tumors  of,  331 
Iritis,  313,  314,  441 

diabetic,  319 

diagnosis  of,  61,  71.  320,  325,  337, 
440,  441 

fibrinous,  318 

gonorrheal,  319,  321 

gouty,  319,  321 

insidious,  318 

malarial,  321, 

parenchymatous,  318 

plastic,  318 

purulent,  318 

quiet,  318 

rheumatic,  314,  319,  321 

sequels  of,  326 

serous,  319,  324 

spongy,  318 

syphilitic,  314,  319,  321 

traumatic,  320,  489 

treatment  of,  321,  326,  552 
Irregular  astigmatism,  167, 187,  410 
Irrigators,  247 
Irritants,  237,  303,  511 
Irritation,    sympathetic,   334,    337, 

340 

Ischemia  of  the  retina,  359 
Itching,  52,  239 
Ivory  exostosis,  476 


INDEX. 


595 


JACKSON,  E.,  77,  103,  121,  143,  190, 
191,  235,  406,  431,  432,  500 

Jacob's  ulcer,  461 

Jamaica  ginger  amblyopia,  402 

Javal,  A.,  Jr.,  190 

Javal,  E.,  236 

Javal  and  Schiotz  ophthalmomuter, 
178 

Jeatfreson,  C.  S.,  566 

Jeauselme,  584 

Jeffries,  B.  J.,  55 

Jeffries,  J.  A.,  236 

Jehin-Prune,  522 

Jennings,  J.  E.,  55 

Jequirity,  300,  513 

Johnson,  W.  B.,  446,  500,  566 

Jonnesco,  T.,  441,  478 

KEKATECTASIA,  309 
Keratcctomy,  548 
Keratitis,  187 

bullous,  286 

diagnosis  of,   277,  281,  286,  294, 
299,  320,  440 

diffuse,  292 

fascicular,  288 

filamentous,  287 

interstitial,  292 

lymphatic,  288 

marginal,  294 

neuropathic,  287 

oyster-shuckers',  494 

parenchymatous,  292 

phlyctenular,  288 

punctate,  297,  318,  324 

sclerosing,  294,  312 

scrofulous,  288,  292,  294 

striate,  297 

superficial  vascular,  292,  298 

trachomatous,  298 

traumatic,  494 

treatment  of,  277,  282,  286,  288- 
291,  296,  299 

ulcerous,  276,  286,  320 

vascular,  288 
Keratoconus,  309 
Keratoglobus,  310*  407 
Keratomalacia,  287 
Kidney  disease,  572 
Kingdon,  383 
Kipp,  C.  J.,  477 
Klebs-Loffler  bacillus,  251,  252,  253, 

281 

Knapp,  Geo.,  274 

Knapp,  H.,  249,  260,  431,  432,  565, 
566 


Knapp,  P.  C.,  236 

Knapp's  roller-operation,  260,  539 

Knies,  Max,  583 

Koller,  Carl,  192,  383 

Kollock,  C.  W.,  406,  566 

Kyanopsia,  48 

LACEIMAL  abscess,  467 

conjunctivitis,  253,  465,  523 

disease,  18,  462.  523 

fistula,  467 

gland,  diseases  of,  467 

obstruction,  465,  466,  523,  540, 542 

regurgitation,  253,  281,  465,  523 

tumor,  465 

Lacrimation,  341,  463,  464,  465,  523 
Lactation,  581 
Lagophthalmos,  456 
Lamina  cribrosa,  86,  91 
Landolt,  E.,  143,  431,  522 
Lang,  W.,  500 
Lanolin,  513 
Lapis  divinus,  512 
Lashes,  56,  261,  454,  529 
Latent  hyperopia,  149 

squint,  204,  225 
Lateral  nystagmus,  235 
Law  of  sines,  108 
Lawford,  J.  B.,  274,  357,  478,  584 
Lawson,  Geo.,  478 
Lead  opacity  of  cornea,  302 

poisoning,  366,  389 
Leeches,  529 

Length  of  visual  axis,  134 
Lens.     See  Crystalline  Lens. 
Lens-series,  79,  118 
Lenses,  112,  164,  167 
Lenticonus,  426 
Leprosy,  577 
Leptothrix,  464 
Letter-blindness,  571 
Leucoma,  70,  301,  405 
Leukemia,  363,  572 
Lid-elevator,  526 

margins,  56,  60,  449 
Lids,  56,  64,  448 

adhesions  of,  66 

bruise  of,  479 

diseases  of,  448 

foreign  body  in,  492 

operations  on,  529 
Liehreich  bandage,  528 
Light  in  pupil,  140 

perception,  30,  140 

projection,  29.  409,  414 

reactions  to,  73 


596 


INDEX. 


Light,  refraction  of,  104 

streak  on  retinal  vessels,  86,  359 

waves,  104 
Lime-burns,  272 
Liude,  Max,  499 
Linear  extraction,  557 
Lines  in  astigmatism,  171 
Liuuell,  E.  H.,  583 
Lipoma,  271,  460 
Lippincott,  J.  A.,  565 
Lippitudo,  449 
Local  anesthesia,  514 
Locomotor  ataxia,  568 
Lopez,  H.,  274 
Loring,  E.  G.,  79,  103 
Loupe,  corneal,  68 
Love,  L.  F.,  383 
Lucciola,  J.,  191 
Lupus,  268,  461 
Luxation  of  eyeball,  480 

of  lens,  424,  439,  445,  480,  482 
Lymphatic  glands,  enlarged,    255, 

453 

Lymphoma,   or    lymphoid    tumor, 
466,  476 

MACKAY,  G.  W.,  383 
Mackenzie,  Win.,  499 
Macula  of  cornea,  70,  301 

lutea,  43,  88,  101 
Macular  reflex,  89 
Maddox,  E.  E.,  121,  228,  229,  235 
Maddox  rod,  228 
Magnet-extraction,  498,  560 
Magnifiers,  68 
Malaria,  577 
Malarial  ulcer,  286 
Malignant  glaucoma,  443 

myopia,  158 
Manifest  hyperopia,  149 
Marginal  keratitis,  294 
Marple,  W.  B.,  236 
Marshall,  C.  D.,  357,  383,  431,  432 
•Marti,  A.,  522 
Mask  to  protect  eye,  528 
Massage,  312,  442,  501 

of  crystalline  lens,  416 
Mature  cataract,  411 
Maxillary  antrum,  477 
McGillivray,  A.,  Mr, 
Measles,  241,  577 

Measurement  of  refraction,  131, 133, 
134 

of  squint,  201,229 
Mechanical  injuries,  479 
Medicated  gelatin  disks,  507,  518 


Medullated  nerve-fibers,  91,  381 

Meibomian  glands,  271 

Melanomata,  331 

Mellinger,  C.,  522 

Meningitis,  343,  381,  567,  579 

Meningocele,  475 

Meniscus  lenses,  115,  189 

Menstruation,  581 

Mental  confusion,  227 

Mercurial   preparations,    303,    509, 

513,  520 

Meridians  of  astigmatism,  169 
Metamorphopsia,  358,  377 
Metastasis,  342,  352,  362 
Meter-angle,  193 
Methyl  alcohol,  400 

violet,  510 

Metric  numbers  of  lenses,  117 
Microphthalmos,  475 
Microscopic  examinations,  67,  242, 

243,  245 

Migraine,  45,  570 
Migratory  ophthalmia,  334 
Milium,  453 
Millikin,  B.  L.,  477 
Mind-blindness,  571 
Miners'  nystagmus,  234 
Mirror,  ophthalmoscopic,  130 

skiascopic,  136,  137 
Misplaced  lashes,  455,  529 

puncta,  464 

Mitigated  silver  nitrate,  512 
Mitvalsky,  478 
Mixed  astigmatism,  173 
Molluscum,  contagious,  452 
Monocular  blindness,  32 

diplopia,  46,  424 

neuritis,  389 

polyopia,  410 

squint,  217 

tests,  32.  46 
Monro,  T.  K.,  177 
Montgomery,  W.  T.,  383 
Morax,  V.,  243,  273,  584 
Morgagnian  cataract,  412 
Mounting  glasses^l89 
Movement,    disorders   of,     17,    191, 

205,  332 

Movements  of  eyeball,  57,  159,  191, 
200 

of  lids,  r>fi 

Moving  objects,  29,  410 
Mucocele,  476,  477 
Mucous  grafts,  538 
Muetze,  H.,  477 
Mules'  operation,  536,  .r>fir> 


INDEX. 


597 


Mules,  P.  H.,  566 

Multiple  images,  46,  219,  410,  424 

neuritis,  391,  569 
Mumps,  467,  579 
Murrell,  T.  E.,  432 
Muscte  volitaiites,  42,  160,  428 
Muscle-stretching,  213 
Muscles,  ocular,  17,  191 

operations  on,  543 
Muscular  balance,  20,  24 

imbalance,  225 

insufficiencies,  225,  568 
Mycotic  ulcer  of  cornea,  286 
Mydriasis,  76,  127,  332,  440 
Mydriatics,  80,  127,  321,  439,  516 

attack,  322 
Myelitis,  569 

Myopia,  65,  123,  133,  134,  155,  345, 
378,  407,  560 

axial,  155 

following  iritis,  326 

malignant,  158,  446 

of  curvature,  155 

preceding  cataract,  410 

progressive,  158 

temporary,  158 
Myopic  astigmatism,  173 

crescent,  100,  101, 161,  345 
Myosis,  76,  129,  316,  332 
Myotics,  129,  442,  519 

NARROWIXG  of  visual  field,  41,  48 
Nasal  disease,  263,  465,  476,  582 

duct,  465,  523,  540 

hemianopsia,  37 
Nausea,  206, 568 
Near-point,  126,  145,  154 

of  convergence,  193,  201,  226 
Near  sight,  155,  162,  410 
Nebula,  70,  301 
Necrosis,  orbital,  470 
Negative  aberration,  186 

scotoma,  39 

Neonatorum,  ophthalmia,  243,  249 
Nerve-head,  85,  94,  391 
Nervous  disease,  567 
Nettleship,  E.,  328,  406,  584 
Neuralgia,  52,  440 
Neurasthenia,  571 
Neuritis,  385,  569 
Neuroma  of  lids,  460 
Neuropathic  or  neuroparalytic  kera- 

titis,  287,  292 
Neuroretinitis,  384 
Nevus,  460 
Night-blindness,  358,  369,  373 


Nipping  of  the  lids,  159 
Nitrate  of  silver,  509,  512 
Nitrobenzol  amblyopia,  400 
Normal  irregular  astigmatism,  188 
Norris,  VVm.  F.,  406,  583 
Noyes,  H.  D.,  190 
Nuclear  cataract,  412 

palsies,  214 
Nuel,  J.  P.,  313,  314 
Numbering  of  lenses,  116,  118 

of  prisms,  111 
Nystagmus,  192,  234 

OBJECT- LENS,  142 
Objective  tests  for  malingering,  405 
Oblique  illumination,  68 
Obliquely  placed  lenses,  164 
Obstruction,  lacrimal,  465 

of  canaliculus,  464 

of  nasal  duct,  465 
Occlusion  of  pupil,  327,  439 
Occupation  of  patient,  21 
Ocular  movements,  191,  192 

palsies,  205 
Oculo-motor  paralvsis,  65,  205,  214, 

218 

Ohlemann,  F.  W.  M.,  522 
Ointments,  513 
Oliver,  C.  A.,  143,  382,  522 
Omerod,  236 
Onyx,  290 

Opacity  of  cornea,  70,  81,  275,  277, 
300,  502 

of  crystalline  lens,  82 

of  optic  nerve-head,  94 

of  vitreous,  82,  83,  335,  370 
Opaque  nerve-fibers,  91,  381 
Operations   for  cataract,   419,   421, 
423,  553 

for  pterygium,  266,  537 

for  ripening  cataract,  416 

for  squint,  214.  222,  225,  233,  470, 
543 

for  symblepharon,  270,  538 

on  conjunctiva,  537 

on  cornea,  545 

on  crystalline  lens,  553 

on  eyeball,  560 

on  iris,  549 

on  lacrimal  passages,  540 

on  lids,  529 

on  muscles.  470,  543 

on  sclera.  549 

ophthalmic,  523,  525 

plastic,  535 
Ophthalmomalacia,  447 


598 


INDEX. 


Ophthalmia,  237,  250 
Egyptian,  256 

gonorrheal,  243,  245,  249,  282 
neonatoruin,  243,  245,  249 
nodosa,  243,  320 
phlyctenular,  261 
purulent,  243 
strumous.  261 
sympathetic,  333,  488 
Ophthalmic  migraine,  45 
Ophthalmometer,  172,  178 
Ophthalmoplegia  externa,  76,  205 

interim,  76,  332 

Ophthalmoscope,  78,  130,  152,  176 
Ophthalmoscopic  examination,  18, 

78,  80,  84,  131,  142.  176,  497 
Optic  atrophy,  98,  391,  398,  567 
choroiditic,  393 
consecutive,  393 
gray,  394,  568 
hereditary,  393 
neuritic,  393 
postpapillitic,  393 
primary,  393 
retinitic,  393 
secondary,  393 
simple,  394 
white,  394 
chiasm,  32 
disk,  84,  93,  383,  443 
foramen,  fracture  of,  479 
nerve,  84,  99,  383,  397 

atrophy.    See  Optic  atrophy. 
head,  384,  397 
neuritis,  385,  391,  567 
papilla,  383 
Optical  center  of  lens,  114,  232 

iridectomy,  421.  551 
Orbit,  disease  of,  468 

foreign  body  in,  492 
Orbital  abscess,  470 
cellulitis,  343,  468,  470 
cysts,  474 
fractures,  479 
optic  neuritis,  391 
periostitis,  470 
tumors,  475 

Organic  compounds  of  silver,  510 
Orthophoria,  226 
Orthoptic  exercises,  223 
Oscillation     of     eyeball,    57,    192, 

234 

Osier,  Wm.,  478 
Ossification  of  choroid,  349 
Osteoma,  271,  476 
Overcoming  prisms,*192 


PAIN,  51,  54,  238,  287,  315,  323,  437 

Pallor  of  optic  disk,  96 

Panas,  P.,  536,  566 

Pannus,  298,  502 

Panophthalmitis,  341,  469 

Papilla,  optic,  383 

Papillae,  enlarged,  244,  253,  258 

Papillary  granulations,  244,  245 

Papillitis,  385 

Papilloma,  271 

Papillomacular  bundle,  391,  397 

Papilloretiuitis,  384 

Paracentesis  of  cornea,  284,  546 

Parallel  lines,  183 

rays,  104 
Paralysis,  diphtheritic,  333 

of  accommodation,  214,  332,  4S1 

of  iris,  76,  127,  332,  481 

of  ocular  muscles,  200,  203,  204, 
214,  479 

of  orbicularis,  456 
Paralytic  squint,  200,  203,  204,  214, 

479 

Parasites  in  vitreous,  430 
Paresis  of  ocular  muscles,  226,  568 
Parinaud's  conjunctivitis,  255 
Park,  J.  W.,  236 
Partial  correction,  154 

tenotomy,  544 

Pathology  of  sympathetic  inflam- 
mation, 335 
Pediculosis,  454 
Pemphigus  of  conjunctiva,  267 
Perception  of  light,  30 
Percival,  A.  S.,  235 
Perforating  corneal  ulcer,  245,  279 
Pergens,  190 

Pericorneal  redness,  61,  315,  494 
Perimeter,  34,  35,  201 
Period  of  adaptation  of  glasses,  189 
Periostitis,  orbital,  470 
Periscopic  lens,  115,  185,  189 
Peritomy,  300,  539 
Permanganate  of  potassium,  510 
Pernicious  anemia,  363,  572 
Peroxid  of  hydrogen,  508,  529 
Persistent  hyaloid  artery,  430 

pupillary  membrane,  353 
Petit,  P.,  273 
Pertussis.  579 
Phillips,  K.  J..  191 
Phlegmon  of  orbit,  468 
Phlyctenular  conjunctivitis,  261 

hyperemia.  61,  262 
Pblyetenule,  262,  288 
Photophobia,  17,  276,  277,  288,  341 


INDEX. 


599 


Phthiriasis  ciliorum,  454 
Phthisis  bulbi,  350 
Physiological  cup,  86,  97 
Physostigmin,  129,  442,  519 
Pigment  in  conjunctiva,  273 

in  cornea,  303 

Pigmentation  of  fundus,  87,  99,  316, 
326,  328 

of  retina,  99,  .361 
Pigmentary  degeneration,  372 
Pilocarpin,  129,  442,  519,  522 
Pince-nez,  189 
Pinguecula,  266,  267 
Pin-hole  disk,  31 
Pipette,  247 
Placido's  disk,  71 
Plane  mirror,  136 
Plano-concave  lens,  115 
Plano-convex  lens,  114 
Plastic  choroiditis,  344 

conjunctivitis,  250 

iritis,  318 

operations,  535 
Pneumococcus,  238,  242,  281 
Point  of  light,  45,  174 

of  reversal,  135,  138,  181 
Poison  ivy  and  oak,  451 
Poisons,  397,  583 
Polycoria,  353 

Polyopia,  410.    See  also  Diplopia. 
Polypi,  nasal,  582 
Position  for  operating,  524 
Positive  aberration,  186 

scotoma,  39,  345 
Posterior  sclerosis,  393,  568 

staphyloma,  162,  313 

symblepharon,  270 

synechia,   71,    7(5,    293.   316,  326, 

328 
Potassium  iodid,  303,  521 

permanganate,  510 
Poultices,  503 

Powder  grains,  492,  494,  547 
Powders,  511 
Preface,  5 

Pregnancy,  366,  581 
Preliminary  iridectomy,  549 
Preparation  of  instruments,  524 

of  patient,  523 

of  surgeon,  524 
Presbyopia,  144,  154,  164 
Pressure-bandage,  528,  529 

on  the  eye,  32 

within  eyeball,  432 
Prince,  A.  E.,  259,  543 
Principal  focus,  116 


Principal  meridians,  169 
Prism  convergence,  193 

diopter,  111 

divergence,  193 
Prismatic  colors,  110 
Prisms,  numbering  of,  110,  111 

refraction  by,  109,  111 

uses   of,    192,   203,  205,  213,  220, 

224,  229,  232,  404 

Probing  lacrimal  passages,  466,  541 
Progressive  myopia,  158,  166 
Projection,  194,  197 

light,  29 
Prolapse  of  iris,  284,  480,  488,  556 

of  lacrimal  gland,  468 

of  lens,  480 

of  vitreous,  499,  556 
Prophylaxis  of  purulent  conjunc- 
tivitis, 248 

of  sympathetic  inflammation,  337 
Proptosis.     See  Exophthalmos. 
Protargol,  247,  510 
Protectors,  528 
Pseudo-glioma,  343,  381,  429 
Pterygium,  265,  537 
Ptosis,  56,  457,  536 

congenital,  458 

operations,  536 

paralytic,  457 
Puerperal  fever,  580 
Pulsating  exophthalmos,  472 
Pulsation    of   retinal    vessels,    86, 

437 

Punctate  keratitis,  297,  318,  324 
Punctum,  diseases  of,  463 

proximum,  126,  145 

remotum,  148 
Pupil,  17,  71,  72,  77,  127,  130 

Argyll-Kobertson,  74 

distortion  of,  317,  324,  327,  353 

in  cataract,  409,  415 

reflex  from,  81,  140,  187 

Wernicke,  38,  75 
Pupillary  reactions,  72 
I'npillometer,  12 
Purkinje,  figures  of,  43 
Purpura,  575 
Purulent  conjunctival  discharge,  66 

conjunctivitis,  243,  469 
Pus-organisms,  281 
Putnam,  J.  J.,  478 
Pyemia,  342,  363,  580 
Pyle,  W.  L.,  382 
Py  ok  tan  in,  510 

QUADRANT  defect,  38 


600 


INDEX. 


Quantitative  perception  of  light,  29, 

414 
Quinin  ainblyopia,  401 

RACE,  257,  374,  438 

Radiating  lines,  175 

Radiographs,  492 

Randall,  B.  A.,  103,  121,  406 

Randolph,  R.  L.,  256,  314,  357,  383, 

478,  566 

Rays  of  light,  104 
Reactions  of  iris  and  pupil,  17,  72 
Reading  bar,  223 
Real  focus,  114 

movement,  137 
Reber,  Wendell,  235 
Records  of  cases,  20 

of  vision,  28 

of  visual  field,  36 
Recovery  after  deviation,  227 
Recurrent    oculomotor     paralysis, 

205,  215 
Red  vision,  48 
Redness  of  conjunctiva,  60 

of  optic  disk,  93 
Reduced  eye,  122 

ocular  tension,  447 
Reeve,  R.  A.,  274 
Reflex  epiphora,  463 

from  cornea,  70,  81,  83 

from  lens,  77 

fundus,  81,  89 
Refracting  angle,  110,  111 

power  of  lens,  116 

power  of  prisms,  110 
Refraction  by  glass.  106 

by  cylindrical  lenses,  167 

by  prisms,  110 

by  spherical  lenses,  113 

measurement  of,  131, 134, 152, 162, 
174 

of  light,  103,  104,  167 

of  the  eye,  123 
Refractive  index,  105 
Regular  astigmatism,  167,  169 
Regurgitation,   lacrimal,    253,  281, 

523 

Reid's  ophthalmometer,  179 
Reik,  H.  O.,  383,  565 
Relapsing  fever,  580 
Relative  divergence,  218 

hemianopsia,  38 

scotoma,  39 

Remedies  and  their  application.  500 
Removal  of  clear  lens  for  myopia, 
165,  560 


Renal  disease,  365,  573 
Rest  of  the  eyes,  500,  501 
Retained  nerve-sheath.    See  Opaque 

nerve-fibers. 
Retina,  87,  90,  92,  357,  567 

glioma  of,  380 

injuries  of,  483,  496 
Retinal  anemia,  359 

anomalies,  381 

apoplexy,  364 

atrophy,  361 

degeneration,  361,  372 

detachment,  166,  377,  573 

embolism,  365,  374 

hemorrhage,  90,  360,  573 

hyperemia,  92,  358 

hyperesthesia,  358 

images,  123,  165,  175,  190 

inflammation,  362 

ischemia,  359 

opacity,  360,  483 

pigment,  99 

pigment-changes,  361,  372 

reflexes,  89,  1(>2 

thrombosis,  365,  376 

vessels,  43,  86,  92,  359,  393 
Retinitis,  348,  362 

albuminuric,  365,  573 

circinate,  371 

diabetic,  368,  574 

diagnosis   of,   362,  364,  366,  370, 
373 

embolic,  362 

from  excessive  light,  371 

gouty,  368 

hemorrhagic,  364 

leukemic,  363 

malarial,  364 

metastatic,  362 

pigmentosa,  372 

proliferate,  371,  427 

punctate,  370 

purulent,  362 

septic,  363 

serous  or  simple,  362 

striate,  370 

syphilitic.  :5(i!) 

treat  incut  of,  362,  364,  365,  367, 

:?7o,  :;T:; 

Retinoscopy,  135 

Retraction 'of  lids,  56,  472,  525 

Retrobulbar    optic    neuritis,     391, 

379 

Retrotarsal  fold,  59 
Reversal,  point  of,  135,  138,  181 
Rhagades,  263,  264,  289,  451 


INDEX. 


601 


Rheumatism,  212,  214,  311,  314, 440, 

574 

Rhiuitis,  582 
Rhomer,  500 
Rhus  poisoning,  451 
Rider,  W.,  54 
Riders,  421 
Ridley,  N.  C.,  356 
Ring  dressing,  528 

scotoma,  41 

ulcer,  278 

Rings  around  the  light,  46 
Ripening  operations,  416 
Risley,  S.  D.,  143,  174, 190,  284,431, 

.  584 

Robertson,  Argyll,  274,  534 
Rodent  ulcer,  461 
Rontgen  rays,  492,  496,  498 
Roller-forceps  operation,  260,  539 
Rosy  zone,  62,  277,  292,  315,  324,  436 
Rotary  deviation,  230 

nystagmus,  234 

variable  prism,  231 
Roy,  Duubar,  383,  406.  584 
Rule,  astigmatism  with  or  against, 

169 
Rupture  of  choroid,  102,  483 

of  eyeball,  480 

of  iris,  481 
Russell,  383 

SAEMISCH  incision,  284,  546 

Salt  solution,  510 

Salycilic  acid  amblyopia,  402 

Santonin,  000 

Sarcoma  of  choroid,  350,  444 

of  conjunctiva,  271 

of  lids,  461 

of  orbit,  475 
Sattler,  R.,  190,  356 
Savage,  G.  C.,  236 
Scalping  lid,  531 
Scars,  17,  485,  486 
Scarlet  fever,  241,  365,  578 
Scheffels,  O.,  190 
Schiotz  and  Javal's  ophthalmome- 

ter,  ITS 

Schleich's  local  anesthesia,  515 
Schlennn,  canal  of,  433,  443 
Schobl,  J.,  382, 
Schmidt-Rimpler,  H.,  431 
Schneideman,  T.  B.,  431 
Schweigger  C.,  236,  431 
Schweinitz,  Geo.  E.  de,  55,  383,  406, 

500,  522,  583 
Schwcinitz,  E.  A.  de,  565 


Schwenk,  P.  N.  K.,  478 
Sclera,  diseasess  of,  311 

thinning  of,  157 

wounds  of,  488,  495 
Scleral,  crescent,  86 

hyperemia,  62 

ring,  86 

staphyloma,  33,  157 
Scleritis,  311,  574 
Sclerosiug  keratitis,  294,  312 
Sclerosis,  spinal,  393,  568 
Sclerotomy,  441,  447,  549 
Scoop-extraction,  425,  557 
Scopolamin,  127,  517,  518 
Scotoma,  39,  345,  397,  403 

central,  40,  397,  569,  574 

color,  40,  397 

negative,  39 

positive,  39,  345 

ring,  41 

temporary,  42,  570 
Scurvy,  575 
Second  sight,  410 
Secondary  cataract,  422 

contraction,  206 

deviation,  206 

Sector-like  defect  of  field,  38,  397 
Senile  cataract,  409 
Sensations,  visual,  44 
Septicemia,  342,  363,  580 
Sequels  of  iritis  and  cyclitis,  326 
Serpent  ulcer,  278,  279,  281 
Sexual  disorders,  581 
Shadow-test,  135 
Sharkey,  S.  J.,  406 
Shaw,  C.  E.,  357 
Shingles,  452 
Short,  O.  J.,  406 
Short  sight,  155 
Shotted-silk  retina,  89 
Shrinking  of  conjunctiva,  260,  261, 
268 

of  eyeball,  350 

of  nerve-head,  391,  393 
Sight.     See  Vision. 
Silver  nitrate,  247,  273,  509,  512 

organic  salts  of,  510 
Simple  dressing.  527 

extraction,  417,  553 

hyperopic  astigmatism,  173 

myopic  astigmatism,  173 

ulcer  of  cornea,  276 
Simulated  amblyopia,  403 
Sinclair,  W.  W.,  477 
Sinuses  adjoining  orbit,  476 
Sketches,  21 


602 


INDEX. 


Skiascopy,  134,  140,  163,  172,  180 

Slit,  stenopaic,  175,  183 

Slitting  canaliculis,  540 

Sloughing  ulcer  of  coruea,  278,  279 

Smallpox,  241,  281,  578 

Smarting,  51,  239 

Smith,  Priestley,  124,  143,  220,  235, 

236,  406,  439,  566 

Snell,  S.,  236,  274,  383,  406,  478,  500 
Suellen,  H.,  27,  54,  236,  566 
Snellen's  test-type,  27 
Snow-blindness,  358 
Snydacker,  E.  F.,  274 
Sodium  chlorid,  511 

ethylate,  461 
Solid  applications  to  conjunctiva, 

506 

Solutions,  507,  513,  515,  519 
Spalding,  J.  A.,  432 
Spasm  of  ciliary  muscle,  149,  333 
Spastic  squint,  234 
Spatula,  corneal,  550 
Spectacles,  189 
Speculum,  eye,  526 
Sphenoidal  disease,  389,  477 
Spherocylindrical  lenses,  164 
Spicer,  W.  T.  H.,  236,  314 
Spinal  disease,  393,  568,  569 
Sponging,  527 
Spring  catarrh,  250 
Spud,  corneal,  545 
Squint,  192 

alternating,  218,  220 

amblyopia  with,  198 

causes  of,  198,  204 

comitant,  200,  203,  214,  222 

concomitant.     See  Comitant. 

constant,  222 

convergent,  200,  222 

diagnosis  of,  199,  206,  210,  219 

divergent,  200,  218 

intermittent,  218 

measurement  of,  201 

monolateral,  220 

operations,  222,  224,  233,  543 

paralytic,  200,  203,  204,  214 

spastic,  234 

treatment  of,  212.  221,  223,  231 

varieties  of,  203,  204 

vertical,  200,  219 
Stains  for  bacteria,  67 
Stand ish,  Myles,  236,  274 
Staphylococcus,  238,  288 
Staj.hyloiiia.  162,  305.  313,  548 
Stark.-y,  H.  M.,  191 
Stellwag's  sign,  472 


Stenopaic  slit,  175,  183 

spectacles,  188 
Stereoscope,  224,  404 
Stereoscopic  effect,  195 
Stephenson,  S.,  274,  356 
Stevens,  E.  W.,  478 
Stevens,  G.  T.,  236 
Stevens's  phorometer,  230 
Stillicidimn  lacriniarum,  462 
Stillson,  J.  p.,  383 
Stinging  pain,  52 
Story,  J.  B.,  103,  357 
Strabismus.    See  Squint. 
Strength  of  lens,  115,  118 

of  prism,  110 
Streptococcus,  238 
Strezminski,  584 
Striate  keratitis,  298 
Stricture,  lacrimal,  465,  542 
Struma,  575 
Strychnin,  521 
Sturm,  focal  interval  of,  170 
Stye,  450 

Styptics,  503,  520,  529 
Subconjunctival     injections,     296, 

348,  507 

Subhyaloid  hemorrhage,  90,  360 
Subjective  symptoms,  44 
Subluxation  of  lens,  425 
Suction-operation,  419,  557 
Sulphate  of  copper,  511 

of  7.inc,  512 

Sunburn  of  conjunctiva,  272 
Superior  oblique,  209,  210 

rectus,  208,  210 
Supplementary  lenses,  120 
Suppression  of  image,  198 
Suppurating  ulcer  of  cornea,  278, 547 
Suprarenal  extract,  520,  529 
Surface  of  cornea,  17 
Sursumduction,  192,  231 
Sursumvergence,  192 
Swanzy,  H.  E.,  77,  236,  583 
Sweet,' W.  M.,  491,  500 
Swelling  of  conjunctiva,  239 

of  lens,  411,  445,  490 

of  lids,  64,  250,  251),  459 

of  optic  disk,  95 
Swollen  cataract,  411,  445,  496 
Sym,  W.  G.,  432 
Syniblepharon,  209,  538 
Sympathetic    nerve,    excision     of 
cervical,  441 

inflammation,  334,  488 

irritation.  33-1,  337,  340 

neurosis,  340 


INDEX. 


603 


Sympathetic  ophthalmia,  333,  488 

Sympathizing  eye,  334 

Synechia,  71,  76,  293,  316,  326,  328 

Synchisis,  428 

Syphilis,  18,  101,  212,  214,  268,  292, 
295,  311,  324,  348,  369,  377, 
390,  445,  467,  475,  575 

Syringing,  540 

Systemic  remedies,  520 

TABLE  of  contents,  7 

Tables,  105,  112,  118,  126,  134,  146 

Tabes  dorsal  is,  568 

Tangent  of  angle  of  squint,  201 

Tannin,  512 

Tapping  sheath  of  optic  nerve,  390 

Tarsal  cyst,  459 

Tarsitis,  450 

Tarsorrhaphy,  533 

Tattooing  the  cornea,  304,  308,  548 

Tay's  choroiditis,  374 

Tear-stone,  464 

Telangiectasis,  460 

Temporal  hemianopsia,  37 

Temporary  amblyopia,  403 

hemianopsia,  38,  42 

myopia,  158 

scotoma,  42 
Tenonitis,  470 

Tenotomy,  214,  222,  234,  543 
Tension,  intra-ocular,  19,  432,  434, 

447 
Test  cards,  28 

colors,  49 

lenses,  119,  152,  183 

letters,  27,  28,  30 

objects,  26,  34 

types,  27,  405 
Tests  of  astigmatism,  178,  184 

of  malingering,  404 

of  monocular  vision,  32 

of  ocular  movements,  57 

of  ocular  tension,  434 

of  scotoma,  40 

of  visual  field,  34 

of  vision.  26,  29 
Tetany,  569 

Theobald,  S.,  236,  478,  541 
Therapeutics,  500 
Thier,  190 

Thiersch  grafting,  260,  270,  535 
Thomas,  ('.  II.,  236,  478,  542 
Thompson,  J.  H.,  273 
Thompson,  J.  L.,  383 
Thomson.  Win.,  55,  175,  176,  190 
Thorington,  J.,  143 


Thrombosis  of  cavernous  sinus,  469 

of  retinal  vesseln,  376 
Tiffany,  F.  B.,  432 
Tilley,  R.,  55 
Tinea  tarsi,  449 
Tobacco  amblyopia,  397 
Tortuous  retinal  vessels,  92 
Total  astigmatism,  180 

hyperopia,  149 

synechia,  328 
Toxic  amblyopias,  397 
diagnosis,  398,  402 
treatment,  399,  402 
Trachoma,  256,  539 

granules.  257 

Trachomatous  keratitis,  298 
Transillumination,  476,  477 
Transient  amblyopia,  403 

hemianopsia,  38,  42 
Transparency  of  media,  21 
Transplantation  of  cornea,  304 

of  epithelial  grafts.  535,  538 

of  pterygiurn,  266,538 
Traumatic  cataract,  482,  489 

cycloplegia,  481 

edema  of  retina,  483 

iridoplegia,  481 
Traumatism.     See  Injuries. 
Tremulous  iris.  332,  423 
Trial-frames,  168 
Trial-set,  119 
Trichiasis,  454,  529 
Trifacial  disease,  569 
Trikresol,  508 
True  image,  196,  207 

scotoma,  39 

Tscherning,  M.,  124,  143 
Tuberculosis  of  choroid,  352,  575 

of  conjunctiva,  268,  575 

of  iris,  330, 575 

of  skin,  461 
Tumors,  intra-ocular,  330,  350,  380 

of  conjunctiva,  271 

of  iris,  330,  408 

of  lacrimal  gland,  488 

of  lids,  459 

of  optic  nerve,  396 

of  orbit,  459 

Turbinals,  hypertrophy  of,  465 
Turner,  W.  A.,  77 
Twitching  of  lids,  129,  457 
Typhoid  fever,  580 
Typhus  fever,  580 

ULCERS  of  cornea,   244,   276,   278, 
286,  546 


604 


INDEX. 


Unequal  pupils,  75 
Union  of  lids,  458,  533 
Uremia,  365,  573 
Use  of  trial -set,  119 
Uthoff,  313 
Uveal  tract,  314 
Uveitis,  334 

VACCINIA,  461,  579 
Variable  prism,  231 

squint,  218 
Varicella,  379 
Variola,  378 
Vascular  disease,  365,  374,  573 

tumor,  332,  460 

Veasey,  C.  A.,  274,  313,  357,  566 
Venous  hyperemia,  63 
Vernal  conjunctivitis,  255 
Vertical  nystagmus,  235 

squint,  208,  209,  219 
Vertigo,  227,  568 
Virtual  focus,  114 
Visual  angle,  25 

centers,  32,  37,  46,  383 

field,   23,   33,   373,   377,  391,  437, 
443,  498 

lines,  192 

plane,  192,  219 

sensations,  44 

tract,  73,  383 

zone,  186 
Vision,  104,  147 

acuteness  of,  20,  21,  25,  30,  387 
Vitiligoidea,  453 
Vitreous  humor,  426 

air-bubbles  in,  497 

blood-vessels  in,  429 

detachment  of,  429 

diseases  of,  426 

fluid,  428 

foreign  body  in,  496 

hemorrhage  into,  429,  482,  497 

inflammation,  429 

membranes  in,  427 

opacity,    82,    83,    160,    335,    370, 
427 

parasites  in,  429 

prolapse  of,  499,  556 

wounds  of,  491,  496 

WADSWORTH,  O.  F.,  383 
Warts,  453 

Washing  conjunctiva,  505 
Watered-silk  retina,  89 


Watery  eye,  462 
Waves  of  light,  104 
Wearing  of  glasses,  189 
Wecker,  L.,  de,  304 
Weeks,  J.  E.,  241,  273,  431,  500 
Weiland,  C.,  55,  235 
Weiss'  reflex,  89,  162 
Wenzel's  extraction,  329,  557 
Wernicke's  reaction  of  pupil,  75 
Whooping-cough,  271,  579 
Wicherkiewicz,  B.,  522 
Wilbrand,  H.,  55 
Wilder,  W.  H.,  314 
Williamson,  R.  T.,  583 
Wilmer,  W.  H.,  190 
Wilson,  H.,  191,  477 
Winking,  excessive,  457 

test,  54 

Wintersteiner,  H.,  383 
Wood,  C.  A.,  383,  406 
Wood  alcohol,  400 
Woods,  Hiram,  236,  406 
Word-blindness.  571 
Working  distance,  147 
Wound  of  ciliary  body,  488 

of  conjunctiva,  487 

of  cornea,  487 
Wounds  of  eyeball,  342 

of  iris,  488 

of  lens,  489 

of  lids,  485 

of  orbit,  486 

of  sclera,  488 

of  vitreous,  491 
Wray,  383 

Wiirdemann,    H.   V.,   54,  190,  274, 
406,  566 

XANTHELASMA,  453 
Xerosis  bacillus,  252 
of  conjunctiva,  268 
X-rays,  492,  496 

YKLLOW  fever,  581 

Yellow  oxid  of  mercury,  264,  513 

Yellow  spot,  43,  88 

ZIMMERMAN,  M.  W.,  356,  566 
Zinc,  chlorid,  511 

ointment,  514 

sulphate,  512 
Zona,  452 

Zone,  pericorneal,  315,  494 
Zoster,  ophthalmic,  287,  292,  452 


Medical  and  Surgical  Works 


PUBLISHED   BY 


W.  B.  SAUNDERS,  925  Walnut  Street,  Philadelphia,  Pa. 


Abbott  on  Transmissible  Diseases   ....  40 
American  Pocket  Medical  Dictionary    .   .  31 
*American  Text-Book  of   Applied   Thera- 
peutics     6 

*American  Text- Book  of  Chemistry  ...  40 
*American  Text-Book  of  Diagnosis  ...  40 
*American  Text-Book  of  Dis.  of  Children  .  n 
*An  American  Text-Book  of  Diseases  of  the 

Eye,  Ear,  Nose,  and  Throat 13 

*An   American  Text-Book  of  Genito-Uri- 

nary  and  Skin  Diseases 12 

*American  Text-Book  of  Gynecology  .  .  .  10 
*American  Text-Book  of  Legal  Medicine  .  40 
'American  Text-Book  of  Obstetrics  ...  7 
*American  Text  Book  of  Pathology  ...  40 
*American  Text-Book  of  Physiology  ...  5 
*American  Text-Book  of  Practice  ....  8 
*American  Text-Book  of  Surgery  .  .  9 
Anders'  Theory  and  Practice  of  Medicine  .  17 

Ashton's  Obstetrics 39 

Atlas  of  Skin  Diseases 24 

Ball's  Bacteriology 39 

Bastin's  Laboratory  Exercises  in  Botany  .  32 

Beck's  Surgical  Asepsis 37 

Boisliniere's  Obstetric  Accidents 35 

Brockway's  Physics 39 

Burr's  Nervous  Diseases 37 

Butler's  Materia  Medica  and  Therapeutics  jo 
Cerna's  Notes  on  the  Newer  Remedies  .  .  28 
Chapin's  Compendium  of  Insanity  ....  31 
Chapman's  Medical  Jurisprudence  .  .  .  .  37 
Church  and  Peterson's  Nervous  and  Men- 
tal Diseases 15 

Clarkson's  Histology 29 

Cohen  and  Eshner's  Diagnosis 39 

Corwin's  Diagnosis  of  the  Thorax   ....  33 

Cragin's  Gynaecology 39 

Crookshank's  Text-Book  of  Bacteriology  .  23 

DaCosta's  Manual  of  Surgery 19 

De  Schweinitz's  Diseases  of  the  Eye  ...  25 
Dorland's  Pocket  Medical  Dictionary  .  .  31 

Dorland's  Obstetrics 37 

Frothingham's  Bacteriological  Guide  ...  26 

Garrigues"  Diseases  of  Women 30 

Gleason's  Diseases  of  the  Ear 39 

*Gould  and  Pyle's  Curiosities  of  Medicine  .  15 

Grafstrom's  Massage 24 

Griffith's  Care  of  the  Baby 34 

Griffith's  Infant's  Weight  Chart 35 

Gross's  Autobiography 22 

Hampton's  Nursing 35 

Hare's  Physiology 39 

Hart's  Diet  in  Sickness  and  in  Health    .    .  32 

Haynes'  Manual  of  Anatomy 37 

Heisler's  Embryology 40 

Hirst's  Obstetrics 16 

Hyde's  Syphilis  and  Venereal  Diseases  .  .  37 
International  Text- Book  of  Surgery  ...  40 

Jackson's  Diseases  of  the  Eye 40 

Jackson  and  Gleason's  Diseases  uf  the  Eye, 

Nose,  and  Throat 39 

Keating's   Pronouncing  Dictionary  ....  22 

Keating's  Life  Insurance 35 

Keen's  Operation  Blanks 32 

Keen's  Surgery  of  Typhoid  Fever  ....  18 


Kyle's  Diseases  of  Nose  and  Throat  .   29,  40 

Laine's  Temperature  Charts 28 

Lockwood's  Practice  of  Medicine    ....  37 

Long's  Syllabus  ol  Gynecology 30 

Macdonald's  Surgical  Diagnosis  and  Treat- 
ment     18 

McFarland's  Pathogenic  Bacteria    ...      26 
Mallory  and  Wright's   Pathological  Tech- 
nique    .18 


Martin's  Surgery 39 

Martin's  Minor  Surgery,  Bandaging,  and 

Venereal  Diseases 39 

Meigs'  Feeding  in  Early  Infancy 26 

Moore's  Orthopedic  Surgery 19 

Morris'  Materia  Medica  and  Therapeutics  39 

Morris'  Practice  of  Medicine 39 

Morten's  Nurses'  Dictionary 34 

Nancrede's  Anatomy  and  Dissection  ...  27 

Nancrede's  Anatomy 39 

Nancrede's  Principles  of  Surgery 40 

Norris'  Syllabus  of  Obstetrical  Lectures       33 

Penrose's  Diseases  of  Women 20 

Powell's  Diseases  of  Children 39 

Pryor's  Pelvic  Inflammations 40 

Pye's  Bandaging  and  Surgical  Dressing    .  19 

Raymond's  Physiology 37 

Saundby's  Renal  and  Urinary  Diseases  .    .  21 
*Saiinder?"  American  Year-Book  of  Medi- 
cine and  Surgery 14 

Saunders'  Medical  Hand-Atbses  .  .  .  .  3,  4 
Saunders'  Pocket  Medical  Formulary  .  .  31 
Saunders'  New  Series  of  Manuals  ...  36,  37 
Saunders'  Series  of  Question  Compends  38,  39 
Sayre's  Practice  of  Pharmac 


ry 

rbi 


...  39 

Semple's  Pathology  and  Morbid  Anatomy  39 
Semple's  Legal  Medicine.  Toxicology,  and 

Hygiene 39 

Senn's  Genitourinary  Tuberculosis    ...  20 

Senn's  Tumors 21 

Senn's  Syllabus  of  Lectures  on  Surgery  .    .  33 
Shaw's  Nervous  Diseases  and  Insanity  .    .  39 

Starr's  Diet- Lists  for  Children 34 

Stelwagon's  Diseases  of  the  Skin 39 

Stengel's  Pathology 16 

Stevens'  Materia  Sled  ca  and  Therapeutics  28 

Stevens'  Practice  of  Medicine 27 

Stewart's  Manual  of  Physiology 33 

Stewart    and    Lawrance's    Medical    Elec- 
tricity       39 

Stoney's  Materia  Medica  for  Nurses  ...  27 
Stoney's  Practical  Points  in  Nursing  ...  23 
Sutton  and  Giles'  Diseases  of  \\  omen  .  25,  37 
Thomas's  Diet-List  and  Sick-Room  Diet- 
ary   34 

Thornton's  Dose-Book  and  Manual  of  Pre- 
scription-Writing  .  .37 


Thresh's  Water  and  Water  Supplies   ...  29 
Van  Valzah  and  Nisbet's  Diseases  of  the 

Stomach 17 

Vecki's  Sexual  Impofnce 29 

Vierordt  and  Stuart  s  Medical  Diagn>  sis    .  24 

Warren's  Surgical  Pathology 21 

Wolffs  Chemistry 39 

Wolff's  Examination  of  Urine   ......  30 


GENERAL   INFORMATION. 


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regardless  of  the  number  of  books  purchased  at  one  time.  Prices 
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(100  titles  to  select  from)  may  be  had  in  this  way  at  catalogue  price, 
including  the  American  Text-Book  Series,  the  Medical  Hand- 
Atlases,  etc.  All  payments  to  be  made  by  mail  or  otherwise,  free 
of  all  expense  to  us. 


SAUNDERS' 

MEDICAL  HAND-ATLASES. 


THE  series  of  books  included  under  this  title  consists  of  authorized  translations 
into  English  of  the  world-famous  Lehmann  Medicinische  Handatlanten, 
which  for  scientific  accuracy,  pictorial  beauty,  compactness,  and  cheap- 
ness surpass  any  similar  volumes  ever  published. 

Each  volume  contains  from  50  to  100  colored  plates,  executed  by  the 
most  skilful  German  lithographers,  besides  numerous  illustrations  in  the  text. 
There  is  a  full  and  appropriate  description,  and  each  book  contains  a  con- 
densed but  adequate  outline  of  the  subject  to  which  it  is  devoted. 

One  of  the  most  valuable  features  of  these  atlases  is  that  they  offer  a  ready 
and  satisfactory  substitute  for  clinical  observation.  Such  observation, 
of  course,  is  available  only  to  the  residents  in  large  medical  centers;  and  even 
then  the  requisite  variety  is  seen  only  after  long  years  of  routine  hospital  work. 
To  those  unable  to  attend  important  clinics  these  books  will  be  absolutely  indis- 
pensable, as  presenting  in  a  complete  and  convenient  form  the  most  accurate  re- 
productions of  clinical  work,  interpreted  by  the  most  competent  of  clinical  teachers. 

While  appreciating  the  value  of  such  colored  plates,  the  profession  has 
heretofore  been  practically  debarred  from  purchasing  similar  works  because  of 
their  extremely  high  price,  made  necessary  by  a  limited  sale  and  an  enormous 
expense  of  production.  In  planning  this  series,  however,  arrangements  were 
made  with  representative  publishers  in  the  chief  medical  centers  of  the  world 
for  the  publication  of  translations  of  the  atlases  into  nine  different  languages, 
the  lithographic  plates  for  all  being  made  in  Germany,  where  work  of  this  kind 
has  been  brought  to  the  greatest  perfection.  The  enormous  expense  of  making 
the  plates  being  shared  by  the  various  publishers,  the  cost  to  each  one  was 
reduced  to  practically  one-tenth.  .Thus  by  reason  of  their  universal  transla- 
tion and  reproduction,  affording  international  distribution,  the  publishers  have 
been  enabled  to  secure  for  these  atlases  the  best  artistic  and  professional 
talent,  to  produce  them  in  the  most  elegant  style,  and  yet  to  offer  them  at  a 
price  heretofore  unapproached  in  cheapness.  The  great  success  of  the 
undertaking  is  demonstrated  by  the  fact  that  the  volumes  have  already  appeared 
in  nine  different  languages — German,  English,  French,  Italian,  Russian, 
Spanish,  Danish,  Swedish,  and  Hungarian. 

In  view  of  the  unprecedented  success  of  these  works,  Mr.  Saunders  has  con- 
tracted with  the  publisher  of  the  original  German  edition  for  one  hundred 
thousand  copies  of  the  atlases.  In  consideration  of  this  enormous  under- 
taking, the  publisher  has  been  enabled  to  prepare  and  furnish  special  additional 
colored  plates,  making  the  series  even  handsomer  and  more  complete  than 
was  originally  intended. 

As  an  indication  of  the  great  practical  value  of  the  atlases  and  of  the 
immense  favor  with  which  they  have  been  received,  it  should  he  noted  that  the 
Medical  Department  of  the  U.  S.  Army  has  adopted  the  "  Atlas  of  Opera- 
tive Surgery  "  as  its  standard,  and  has  ordered  the  book  in  large  quantities  for 
distribution  to  the  various  regiments  and  army  posts. 

The  same  careful  and  competent  editorial  supervision  has  been  secured  in 
the  English  edition  as  in  the  originals.  The  translations  have  been  edited  by 
the  leading  American  specialists  in  the  different  subjects.  The  volumes  are 
of  a  uniform  and  convenient  size  (5  X  7/^  inches)>and  are  substantially  bound. 

(For  List  of  Volumes  in  this  Series,  see  next  page.} 
3 


SAUNDERS'  MEDICAL  HAND-ATLASES. 


VOLUMES  NOW  READY. 

Atlas  of  Internal  Medicine  and  Clinical  Diagnosis.  By  DK.  CHR. 
JAKOB,  of  Erlangen.  'Edited  by  AUGUSTUS  A.  ESHNER,  M.  D.,  Professor 
of  Cliiiical  Medicine  Philadelphia  Polyclinic.  68  colored  plates,  64  text 
illustrations,  and  259  pages  of  text.  Cloth,  $3.00  net. 

Atlas  of  Legal  Medicine.  By  DR.  E.  R.  VON  HOFMANN,  of  Vienna.  Edited 
by  FREDKRICK  PETERSON,  M.  D.,  Clinical  Professor  of  Mental  Diseases, 
Woman's  Medical  College,  New  York ;  Chief  of  Clinic,  Nervous  Dept., 
College  of  Physicians  and  Surgeons,  New  York.  With  120  colored  figures 
on  56  plates,  and  193  beautiful  half-tone  illustrations.  Cloth,  $3.50  net. 
"  Hotmann's  'Atlas  of  Legal  Medicine'  is  a  unique  work.  This  immense  field  finds  in  this 

book  a  pictorial  presentation  that  far  excels  anything  with  which  we  are  familiar  in  any  other 

work." — Philadelphia.  Medical  Journal. 

Atlas  of  Diseases  of  the  Larynx.  By  DR.  L.  GRUNWALD,  of  Munich. 
Edited  by  CHARLES  P.  GRAYSON,  M.  D.,  Physician-in-Charge,  Throat  and 
Nose  Department,  Hospital  of  the  University  of  Pennsylvania.  With  107 
colored  figures  on  44  plates,  25  text-illustrations,  and  103  pages  of  text. 
Cloth,  $2.50  net. 

Atlas  of  Operative  Surgery.  By  DR.  O.  ZUCKERKANDL,  of  Vienna.  Edited 
by  J.  CHALMERS  DACOSTA,  M.  D.,  Clinical  Professor  of  Surgery,  Jefferson 
Medical  College,  Philadelphia.  With  24  colored  plates,  217  text-illus- 
trations, and  395  pages  of  text.  Cloth,  $3.00  net. 

"  We  know  of  no  other  work  that  combines  such  a  wealth  of  beautiful  illustrations  with 
clearness  and  conciseness1  of  language,  that  is  so  entirely  abreast  of  the  latest  achievements, 
and  so  useful  both  for  the  beginner  and  for  one  who  wishes  to  increase  his  knowledge  of  oper- 
ative surgery." — Miinchener  medicinisclie  Wochenschrift. 

Atlas  of  Syphilis  and  the  Venereal  Diseases.  By  PROF.  DR.  FRANZ 
MR  ACER,  of  Vienna.  Edited  by  L.  BOLTON  BANGS,  M.  D.,  Professor  of 
Geni to- Urinary  Surgery,  University  and  Bellevue  Hospital  Medical  College, 
New  York.  With  71  colored  plates  from  original  water- colors,  1 6  black- 
and-white  illustrations,  and  122  pages  of  text.  Cloth,  $3.50  net. 

Atlas  of  External  Diseases  of  the  Eye.     By  DR.  O.  HAAB,  of  Zurich. 

Edited  by  G.  E.  DE  SCHWEINITZ,  M.  D.,  Professor  of  Ophthalmology, 
Jefferson  Medical  College,  Philadelphia  With  76  colored  illustrations  on 
40  plates,  and  228  pages  of  text.  Cloth,  $3.00  net. 

Atlas  of  Skin  Diseases.  By  PROK.  DR.  FRANZ  MRACEK,  of  Vienna. 
Edited  by  HENRY  W.  STELWAGON,  M.  D  ,  Clinical  Professor  of  Derma- 
tology, Jefferson  Medical  College,  Philadelphia.  With  63  colored  plates, 
39  beautiful  half-tone  illustration-;,  and  200  pages  of  text.  Cloth,  $3.50  net. 

NEW  VOLUME  IN  PRESS. 

Atlas  of  Diseases  Caused  by  Accidents.  By  DR.  ED.  GOLEBIEWSKI, 
of  Berlin.  Edited  with  additions  by  PEARCE  BAILEY,  A.  M..  M.  D.,  At- 
tending Physician  to  Department  of  Corrections  and  to  Almshouse  and 
Incurable  Hospitals,  New  York  City.  48  colored  plates,  200  text-illustra- 
tions, and  about  400  pages  of  text. 

IN  PREPARATION. 

Atlas  of  Pathological  Histology.  Atlas  of  Operative  Gynecology. 

Atlas  of  Orthopedic  Surgery.  Atlas  of  Psychiatry. 

Atlas  of  General  Surgery.  Atlas  of  Diseases  of  the  Ear. 


CATALOGUE    OF  MEDICAL    WORKS. 


5 


*AN  AMERICAN  TEXT-BOOK  OF  PHYSIOLOGY.  Edited  by 
WILLIAM  H.  HOWELL,  PH.  D.,  M.  D.,  Professor  of  Physiology  in  the 
Johns  Hopkins  University,  Baltimore,  Md.  One  handsome  octavo  volume 
of  1052  pages,  fully  illustrated.  Prices  :  Cloth,  $6.00  net;  Sheep  or  Half- 
Morocco,  $7.00  net. 

This  work  is  the  most  notable  attempt  yet  made  in  America  to  combine  in 
ane  volume  the  entire  subject  of  Human  Physiology  by  well-known  teachers 
who  have  given  especial  study  to  that  part  of  the  subject  upon  which  they  write. 
The  completed  work  represents  the  present  status  of  the  science  of  Physiology, 
particularly  from  the  standpoint  of  the  student  of  medicine  and  of  the  medical 
practitioner. 

The  collaboration  of  several  teachers  in  the  preparation  of  an  elementary  text- 
book of  physiology  is  unusual,  the  almost  invariable  rule  heretofore  having  been 
for  a  single  author  to  write  the  entire  book.  One  of  the  advantages  to  be  derived 
from  this  collaboration  method  is  that  the  more  limited  literature  necessary  for 
consultation  by  each  author  has  enabled  him  to  base  his  elementary  account 
upon  a  comprehensive  knowledge  of  the  subject  assigned  to  him ;  another,  and 
perhaps  the  most  important,  advantage  is  that  the  student  gains  the  point  of  view 
of  a  number  of  teachers.  In  a  measure  he  reaps  the  same  benefit  as  would  be 
obtained  by  following  courses  of  instruction  under  different  teachers.  The 
different  standpoints  assumed,  and  the  differences  in  emphasis  laid  upon  the 
various  lines  of  procedure,  chemical,  physical,  and  anatomical,  should  give  the 
student  a  better  insight  into  the  methods  of  the  science  as  it  exists  to-day.  The 
work  will  also  be  found  useful  to  many  medical  practitioners  who  may  wish  to 
keep  in  touch  with  the  development  of  modern  physiology. 

CONTRIBUTORS : 


HENRY  P.  BOWDITCH,  M.  D., 

Professor  of  Physiology,  Harvard  Medi- 
cal School. 

JOHN  G.  CURTIS,  M.  D., 

Professor  of  Physiology,  Columbia  Uni- 
versity, N.  Y.  (College  of  Physicians 
and  Surgeons). 

HENRY  H.  DONALDSON,  Ph.  D., 

Head-Professor  of  Neurology,  Univer- 
sity of  Chicago. 

W.  H.  HOWELL,  Ph.  D.,  M.  D., 

Professor  of  Physiology,  Johns  Hopkins 
University. 

FREDERIC  S.  LEE,  Ph.  D., 

Adjunct  Professor  of  Physiology,  Colum- 
bia University,  N.  Y.  (College  of 
Physicians  and  Surgeons). 


WARREN  P.  LOMBARD,  M.  DM 

Professor   of  Physiology,  University  of 
Michigan. 

GRAHAM  LUSK,  Ph.  D., 

Professor  *of  Physiology,   Yale   Medical 
School. 

W.  T.  PORTER,  M.D., 

Assistant  Professor  of  Physiology,  Har- 
vard Medical  School. 

EDWARD  T.  REICHERT,  M.D., 

Professor  of  Physiology,  University  of 
Pennsylvania. 

HENRY  SEWALL,  Ph.D.,  M.  D., 

Professor  of  Physiology,  Medical  Deparfr 
ment,  University  of  Denver. 


"  We  can  commend  it  most  heartily,  not  only  to  all  students  of  physiology,  but  to  every 
physician  and  pathologist,  as  a  valuable  and  comprehensive  work  of  reference,  written  by 
men  who  are  of  eminent  authority  in  their  own  special  subjects."  —  London  Lancet. 

"  To  the  practitioner  of  medicine  and  to  the  advanced  student  this  volume  constitutes, 
we  believe,  the  best  exposition  of  the  present  status  of  the  science  of  physiology  in  the  Eng- 
lish language." — American  Journal  of  the  Medical  Sciences. 


W.    B.    SAUNDERS1 


*AN  AMERICAN  TEXT-BOOK  OF  APPLIED  THERAPEU- 
TICS. For  the  Use  of  Practitioners  and  Students.  Edited  by 
JAMES  C.  WILSON,  M.  D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine  in  the  Jefferson  Medical  College.  One  handsome  octavo 
volume  of  1326  pages.  Illustrated.  Prices:  Cloth,  $7.00  net;  Sheep  or 
Half- Morocco,  $8.00  net. 

The  arrangement  of  this  volume  has  been  based,  so  far  as  possible,  upon 
modern  pathologic  doctrines,  beginning  with  the  intoxications,  and  following 
with  infections,  diseases  due  to  internal  parasites,  diseases  of  undetermined 
origin,  and  finally  the  disorders  of  the  several  bodily  systems — digestive,  re- 
spiratory, circulatory,  renal,  nervous,  and  cutaneous.  It  was  thought  proper  to 
include  also  a  consideration  of  the  disorders  of  pregnancy. 

The  articles,  with  two  exceptions,  are  the  contributions  of  American  writers. 
Written  from  the  standpoint  of  the  practitioner,  the  aim  of  the  work  is  to  facili- 
tate the  application  of  knowledge  to  the  prevention,  the  cure,  and  the  allevia- 
tion of  disease.  The  endeavor  throughout  has  been  to  conform  to  the  title  of 
the  book — Applied  Therapeutics — to  indicate  the  course  of  treatment  to  be 
pursued  at  the  bedside,  rather  than  to  name  a  list  of  drugs  that  have  been  used 
at  one  time  or  another. 

The  list  of  contributors  comprises  the  names  of  many  who  have  acquired  dis- 
tinction as  practitioners  and  teachers  of  practice,  of  clinical  medicine,  and  of 
the  specialties. 

CONTRIBUTORS : 


Dr.  I.  E.  Atkinson,  Baltimore,  Md. 
Sanger  Brown,  Chicago,  lil. 
John  B.  Chapin,  Philadelphia,  Pa. 
William  C.  Dabney,  Charlottesville,  Va. 
John  Chalmers  DaCosta,  Philada.,  Pa. 
I.  N.  Danforth,  Chicago,  111. 
John  L.  Dawson,  Jr.,  Charleston,  S.  C. 
F.  X.  Dercum,  Philadelphia,  Pa. 
George  Dock,  Ann  Arbor,  Mich. 
Robert  T.  Edes,  Jamaica*  Plain.  Mass. 
Augustus  A.  Eshner,  Philadelphia,  Pa. 
J.  T.  Eskridge,  Denver,  Ccl. 
F.  Forchheimer,  Cincinnafi,  O. 
Carl  Frese,  Philadelphia,  Pa. 
Edwin  E.  Graham,  Philadelphia,  Pa. 
John  Guiteras,  Philadelphia,  Pa. 
Frederick  P.  Henry,  Philadelphia,  Pa. 
Guy  Hinsdale,  Philadelphia,  Pa. 
Orville  Horwitz,  Philadelphia,  Pa. 
W.  W.  Johnston,  Washington,  D.  C. 
Ernest  Laplace,  Philadelphia,  Pa. 
A.  Laveran,  Pans,  France. 

"As  a  work  either  for  study  or  reference  it  will  be  of  great  value  to  the  practitioner,  as 
it  is  virtually  an  exposition  of  such  clinical  therapeutics  as  experience  has  taught  to  be  of 
the  most  value.  Taking  it  all  in  all,  no  recent  publication  on  therapeutics  can  be  compared 
with  this  one  in  practical  value  to  the  working  physician." — Chicago  Clinical  Review. 

"The  whole  field  of  medicine  has  been  well  covered.  The  work  is  thoroughly  practical, 
and  while  it  is  intended  for  practitioners  and  students,  it  is  a  better  book  for  the  general 
practitioner  than  frr  the  student.  The  young  practitioner  especially  will  find  it  extremely 
suggestive  and  helpful  " — The  Indian  Lancet. 


Dr.  James  Hendrie  Lloyd,  Philadelphia,  Pa. 
John  Noland  Mackenzie,  Baltimore,  Md. 
J.  W.  McLaughlin,  Austin,  Texas. 
A.  Lawrence  Mason,  Boston,  Mass. 
Charles  K.  Mills,  Philadelphia,  Pa. 
John  K.  Mitchell,  Philadelphia,  Pa. 
W.  P.  Northrup,  New  York  City. 
William  Osier,  Baltimore,  Md. 
Frederick  A.  Packard,  Philadelphia,  Pa. 
Theophilus  Parvin,  Philadelphia,  Pa. 
Beaven  Rake,  London,  England. 
E.  O.  Shakespeare.  Philadelphia,  Pa. 
Wharton  Sinkler,  Philadelphia,  Pa. 
Louis  Starr,  Philadelphia,  Pa. 
Henry  W.  Stelwagon,  Philadelphia,  Pa. 
James  Stewart,  Montreal,  Canada. 
Charles  G.  Stockton,  Buffalo,  N.  Y. 
Tames  Tyson,  Philadelphia,  Pa. 
/ictor  C.  Vaughan,  Ann  Arbor,  Mich. 

Iames  T.  Whittaker,  Cincinnati,  O. 
.  C.  Wilson,  Philadelphia,  Pa. 


|al 

Yi, 


CATALOGUE    OF  MEDICAL    WORKS. 


*AN  AMERICAN  TEXT-BOOK  OF  OBSTETRICS.  Edited  by 
RICHARD  C.  NORRIS,  M.  D. ;  Art  Editor,  ROBERT  L.  DICKINSON,  M.  D. 
One  handsome  octavo  volume  of  over  1000  pages,  with  nearly  900  colored 
and  half-tone  illustrations.  Prices :  Cloth,  $7.00  net ;  Sheep  or  Half 
Morocco,  $8.00  net. 

The  advent  of  each  successive  volume  of  the  series  of  the  AMERICAN  TEXT- 
BOOKS has  been  signalized  by  the  most  flattering  comment  from  both  the  Press 
and  the  Profession.  The  high  consideration  received  by  these  text-books,  and 
their  attainment  to  an  authoritative  position  in  current  medical  literature,  have 
been  matters  of  deep  international  interest,  which  finds  its  fullest  expression  in 
the  demand  for  these  publications  from  all  parts  of  the  civilized  world. 

In  the  preparation  of  the  "AMERICAN  TEXT-BOOK  OF  OBSTETRICS"  the 
editor  has  called  to  his  aid  proficient  collaborators  whose  professional  prominence 
entitles  them  to  recognition,  and  whose  disquisitions  exemplify  Practical 
Obstetrics.  While  these  writers  were  each  assigned  special  themes  for  dis- 
cussion, the  correlation  of  the  subject-matter  is,  nevertheless,  such  as  ensures 
logical  connection  in  treatment,  the  deductions  of  which  thoroughly  represent 
the  latest  advances  in  the  science,  and  which  elucidate  the  best  modern  methods 
of  procedure. 

The  more  conspicuous  feature  of  the  treatise  is  its  wealth  of  illustrative 
matter.  The  production  of  the  illustrations  had  been  in  progress  for  several 
years,  under  the  personal  supervision  of  Robert  L.  Dickinson,  M.  D.,  to  whose 
artistic  judgment  and  professional  experience  is  clue  the  most  sumptuously 
illustrated  work  of  the  period.  By  means  of  the  photographic  art,  combined 
with  the  skill  of  the  artist  and  draughtsman,  conventional  illustration  is  super- 
seded by  rational  methods  of  delineation. 

Furthermore,  the  volume  is  a  revelation  as  to  the  possibilities  that  may  be 
reached  in  mechanical  execution,  through  the  unsparing  hand  of  its  publisher. 


CONTRIBUTORS : 


Dr.  James  C.  Cameron. 
Edward  P.  Davis. 
Robert  L.  Dickinson. 
Charles  Warrington  Earle. 
James  H.  Etheridge. 
Henry  J.  Garncues. 
Barton  Cooke  Hirst. 
Charles  Jewett. 


Dr.  Howard  A.  Kelly. 
Richard  C.  Norris. 
Chauncey  D.  Palmer. 
Theophilus  Parvin. 
George  A.  Piersol. 
Edward  Reynolds. 
Henry  Schwarz. 


"At  first  glance  we  are  overwhelmed  by  the  magnitude  of  this  work  in  several  respects, 
viz.  :  First,  by  the  size  of  the  volume,  then  by  the  array  of  eminent  teachers  in  this  depart- 
ment who  have  taken  part  in  its  production,  then  by  the  profuseness  and  character  of  the 
illustrations,  and  last,  but  not  least,  the  conciseness  and  clearness  with  which  the  text  is  ren- 
dered. This  is  an  entirely  new  composition,  embodying  the  highest  knowledge  of  the  art  as 
it  stands  to-day  by  authors  who  occupy  the  front  rank  in  their  specialty,  and  there  are  many 
of  them.  We  cannot  turn  over  these  pages  without  being  struck  by  the  superb  illustrations 
which  adorn  so  many  of  them.  We  are  confident  that  this  most  practical  work  will  find 
instant  appreciation  by  practitioners  as  well  as  students." — New  York  Medical  Times. 

Permit  me  to  say  that  your  American  Text-Book  of  Obstetrics  is  the  most  magnificent 
medical  work  that  I  have  ever  seen.  I  congratulate  you  and  thank  you  for  this  superb  work, 
which  alone  is  sufficient  to  place  you  first  in  the  ranks  of  medical  publishers. 

With  profound  respect  I  am  sincerely  yours,  ALEX.  J.  C.  SKENB. 


W.    B.   SAUNDERS 


*AN  AMERICAN  TEXT-BOOK  OF  THE  THEORY  AND 
PRACTICE  OF  MEDICINE.  By  American  Teachers.  Edited 
by  WILLIAM  PEPPER,  M.  D.,  LL.D.,  Provost  and  Professor  of  the  Theory 
and  Practice  of  Medicine  and  of  Clinical  Medicine  in  the  University  of 
Pennsylvania.  Complete  in  two  handsome  royal-octavo  volumes  of  about 
looo  pages  each,  with  illustrations  to  elucidate  the  text  wherever  necessary. 
Price  per  Volume  :  Cloth,  #5.00  net;  Sheep  or  Half-Morocco,  $6.00  net. 

VOLUME  I.  CONTAINS: 


Hygiene.— Fevers  (Ephemeral,  Simple  Con- 
tinued, Typhus,  Typhoid,  Epidemic  Cerebro- 
spinal  Meningitis,  and  Refapsing). — Scarla- 
tina, Measles,  Rotheln,  Variola,  Varioloid, 
Viccinia,Varicella,  Mumps, Whooping-cough, 
Anthrax,  Hydrophobia,  Trichinosis,  Actino- 


mycosis,  Glanders,  and  Tetanus.— Tubercu- 
losis, Scrofula,  Syphilis,  Diphtheria,  Erysipe- 
las, Malaria,  Cholera,  and  Yellow  Fever. — 
Nervous,  Muscular,  and  Mental  Diseases  etc. 


VOLUME   II.  CONTAINS: 


Urine  (Chemistry  and  Microscopy).— Kid- 
ney and  Lungs. — Air-passages  (Larynx  and 
Bronchi)  and  Pleura. — Pharynx,  CEsophagus, 
Stomach  and  Intestines  (including  Intestinal 
Parasites),  Heart,  Aorta,  Arteries  and  Veins. 


—Peritoneum, Liver, and  Pancreas.— Diathet- 
ic  Diseases  (Rheumatism,  Rheumatoid  Ar- 
thritis, Gout,  Lithaemia,  and  Diabetes.)— 
Blood  and  Spleen. — Inflammation,  Embolism, 
Thrombosis,  Fever,  and  Bacteriology. 


The  articles  are  not  written  as  though  addressed  to  students  in  lectures,  but 
are  exhaustive  descriptions  of  diseases,  with  the  newest  facts  as  regards  Causa- 
tion, Symptomatology,  Diagnosis,  Prognosis,  and  Treatment,  including  a  large 
number  of  approved  formulae.  The  recent  advances  made  in  the  study 
of  the  bacterial  origin  of  various  diseases  are  fully  described,  as  well  as  the 
bearing  of  the  knowledge  so  gained  upon  prevention  and  cure.  The  subjects 
of  Bacteriology  as  a  whole  and  of  Immunity  are  fully  considered  in  a  separate 
section. 

Methods  of  diagnosis  are  given  the  most  minute  and  careful  attention,  thus 
enabling  the  reader  to  learn  the  very  latest  methods  of  investigation  without 
consulting  works  specially  devoted  to  the  subject. 


CONTRIBUTORS : 


Dr.  J.  S.  Billings,  Philadelphia. 
Francis  Delafie"  " 


ild,  New  York. 
Reginald  H.  Fitz,  Boston. 
James  W.  Holland,  Philadelphia. 
Henry  M.  Lyman,  Chicago. 
William  Osier,  Baltimore. 


W.  Oilman  Thompson,  Ne*w  York. 
W.  H.  Welch,  Baltimore. 
James  T.  Whittaker,  Cincinnati. 
James  C.  Wilson,  Philadelphia. 
Horatio  C.  Wood,  Philadelphia. 


"  We  reviewed  the  first  volume  of  this  work,  and  said :  '  It  is  undoubtedly  one  of  the  best 
text-books  on  the  practice  of  medicine  which  we  possess.'  A  consideration  of  the  second 
«.nd  last  volume  leads  us  to  modify  that  verdict  and  to  say  that  the  completed  work  is,  in  our 
opinion,  THE  BBST  of  its  kind  it  has  ever  been  our  fortune  to  see.  It  is  complete,  thorough, 
accurate,  and  clear.  It  is  well  written,  well  arranged,  well  printed,  well  illustrated,  and  well 
bound.  It  is  a  model  of  what  the  modern  text-book  should  be." — New  Yen  k  Medicml  "Journal. 

"  A  libiary  upon  modern  medical  art.  The  work  must  promote  the  wider  diffusion  of 
sound  knowledge." — American  Lancet. 

"A  trusty  counsellor  for  the  practitioner  or  senior  student,  on  which  he  may  implicitly 
:*ly." — Edinburgh  Medical  Journal. 


CATALOGUE    OF  MEDICAL    WORKS. 


*AN  AMERICAN  TEXT-BOOK  OF  SURGERY.  Edited  by  WIL- 
LIAM W.  KEEN,  M.  D.,  LL.D.,  and  J.  WILLIAM  WHITE,  M.  D.,  PH.  D, 
Forming  one  handsome  royal  octavo  volume  of  1230  pages  (lox  7  inches), 
with  496  wood-cuts  in  text,  and  37  colored  and  half-tone  plates,  many  of 
them  engraved  from  original  photographs  and  drawings  furnished  by  the 
authors.  Price  :  Cloth,  $7.00  net;  Sheep  or  Half  Morocco,  $8.00  net. 

THIRD  EDITION,  THOROUGHLY  REVISED. 

In  the  present  edition,  among  the  new  topics  introduced  are  a  full  considera- 
tion of  serum-therapy  ;  leucocytosis  ;  post-operative  insanity;  the  use  of  dry  heat 
at  high  temperatures ;  Kronlein's  method  of  locating  the  cerebral  fissures ; 
Hoffa's  and  Lorenz's  operations  of  congenital  dislocations  of  the  hip;  Allis's  re- 
searches on  dislocations  of  the  hip-joint ;  lumbar  puncture ;  the  forcible  reposi- 
tion of  the  spine  in  Pott's  disease;  the  treatment  of  exophthalmic  goiter;  the 
surgery  of  typhoid  fever ;  gastrectomy  and  other  operations  on  the  stomach ; 
new  methods  of  operating  upon  the  intestines;  the  use  of  Kelly's  rectal  specula; 
the  surgery  of  the  ureter ;  Schleich's  infiltration-method  and  the  use  of  eucain 
for  local  anesthesia;  Krause's  method  of  skin-grafting;  the  newer  methods  of 
disinfecting  the  hands ;  the  use  of  gloves,  etc.  The  sections  on  Appendicitis, 
on  Fractures,  and  on  Gynecological  Operations  have  been  revised  and  enlarged. 
A  considerable  number  of  new  illustrations  have  been  added,  and  enhance  the 
value  of  the  work. 

The  text  of  the  entire  book  has  been  submitted  to  all  the  authors  for  their 
mutual  criticism  and  revision — an  idea  in  book-making  that  is  entirely  new  and 
original.  The  book  as  a  whole,  therefore,  expresses  on  all  the  important  sur- 
gical topics  of  the  day  the  consensus  of  opinion  of  the  eminent  surgeons  who 
have  joined  in  its  preparation. 

One  of  the  most  attractive  features  of  the  book  is  its  illustrations.  Very 
many  of  them  are  original  and  faithful  reproductions  of  photographs  taken 
directly  from  patients  or  from  specimens. 

CONTRIBUTORS : 


Dr.  Phineas  S.  Conner,  Cincinnati. 
Frederic  S.  Dennis,  New  York 
William  W.  Keen,  Philadelphia. 
Charles  B    Nancrede,  Ann  Arbor  Mich. 
Roswell  Park,  Buffalo,  New  York. 
Lewis  S.  Pilcher,  New  York. 


Dr.  Nicholas  Senn,  Chicago. 

Francis  J.  Shepherd,  Montreal,  Canada. 

Lewis  A.  Slimson,  New  York. 

J.  Collins  Warren,  Boston. 

J.  William  White,  Philadelphia. 


"  If  this  text-book  is  a  fair  reflex  of  the  present  position  of  American  surgery,  we  must 
admit  it  is  of  a  very  high  order  of  merit,  and  that  English  surgeons  will  have  to  look  very 
carefully  to  their  laurels  if  they  are  to  preserve  a  position  in  the  van  of  surgical  practice."— 
London  Lancet. 


10  W.   B,   SAUNDERS 


*AN  AMERICAN  TEXT-BOOK  OF  GYNECOLOGY,  MEDICAL 
AND  SURGICAL,  for  the  use  of  Students  and  Practitioners. 
Edited  by  J.  M.  BALDY,  M.  D.  Forming  a  handsome  royal-octavo  volume 
of  718  pages,  with  341  illustrations  in  the  text  and  38  colored  and  half- 
tone plates.  Prices  :  Cloth,  $6.00  net;  Sheep  or  Half- Morocco,  $7.00  net. 

SECOND  EDITION,  THOROUGHLY  REVISED. 

In  this  volume  all  anatomical  descriptions,  excepting  those  essential  to  a  cleat 
understanding  of  the  text,  have  been  omitted,  the  illustrations  being  largely  de- 
pended upon  to  elucidate  the  anatomy  of  the  parts.  This  work,  which  is 
thoroughly  practical  in  its  teachings,  is  intended,  as  its  title  implies,  to  be  a 
working  text-book  for  physicians  and  students.  A  clear  line  of  treatment  has 
been  laid  down  in  every  case,  and  although  no  attempt  has  been  made  to  dis- 
cuss mooted  points,  still  the  most  important  of  these  have  been  noted  and  ex- 
plained. The  operations  recommended  are  fully  illustrated,  so  that  the  reader, 
having  a  picture  of  the  procedure  described  in  the  text  under  his  eye,  cannot  fail 
to  grasp  the  idea.  All  extraneous  matter  and  discussions  have  been  carefully 
excluded,  the  attempt  being  made  to  allow  no  unnecessary  details  to  cumber 
the  text.  The  subject-matter  is  brought  up  to  date  at  every  point,  and  the 
work  is  as  nearly  as  possible  the  combined  opinions  of  the  ten  specialists  who 
figure  as  the  authors. 

In  the  revised  edition  much  new  material  has  been  added,  and  some  of  the 
old  eliminated  or  modified.  More  than  forty  of  the  old  illustrations  have  been 
replaced  by  new  ones,  which  add  very  materially  to  the  elucidation  of  the 
text,  as  they  picture  methods,  not  specimens.  The  chapters  on  technique  and 
after-treatment  have  been  considerably  enlarged,  and  the  portions  devoted  to 
plastic  work  have  been  so  greatly  improved  as  to  be  practically  new.  Hyste- 
rectomy has  been  rewritten,  and  all  the  descriptions  of  operative  procedures 
have  been  carefully  revised  and  fully  illustrated. 


CONTRIBUTORS : 


Dr.  Henry  T.  Byford. 
John  M.  Baldy. 
Edwin  Cragin. 
I.  H.  Etheridge. 
William  Goodell. 


Dr.  Howard  A.  Kelly. 
Florian  Krug. 
E.  E.  Montgomery. 
William  R.  Pryor. 
George  M.  Tuttle. 


"The  most  notable  contribution  to  gynecological  literature  since  1887 and  the  most 

Complete  exponent  of  gynecology  which  we  have.  No  subject  seems  to  have  been  ntglected. 
....  and  the  gynecologist  and  surgeon,  and  the  general  practitioner  who  has  any  desire 
to  practise  diseases  of  women,  will  find  it  of  practical  value.  In  the  matter  of  illustrations 
and  plates  the  book  surpasses  anything  we  have  seen." — Boston  Medical  and  Surgical 
Journal. 

"A  thoroughly  modern  text-book,  and  gives  reliable  and  well-tempered  advice  and  in- 
struction."— Edinburgh  Medical  Journal. 

"  The  harmony  of  its  conclusions  and  the  homogeneity  of  its  style  give  it  an  individuality 
which  suggests  a  single  rather  than  a  multiple  authorship." — Annats  of  Surgery. 

"  It  must  command  attention  and  respect  as  a  worthy  representation  of  our  advanced 
clinical  teaching." — American  Journal  of  Medical  Sciences. 


CATALOGUE    OF  MEDICAL    WORKS. 


II 


*AN  AMERICAN  TEXT-BOOK  OF  THE  DISEASES  OF  CHIL- 
DREN. By  American  Teachers.  Edited  by  Louis  STARR,  M.  D., 
assisted  by  THOMPSON  S.  WESTCOTT,  M.  D.  In  one  handsome  royal-8vo 
volume  of  1244  pages,  profusely  illustrated  with  wood-cuts,  half-tone  and 
colored  plates.  Net  Prices:  Cloth,  $7.00;  Sheep  or  Half-Morocco,  $8.00. 

SECOND  EDITION,  REVISED  AND  ENLARGED. 

The  plan  of  this  work  embraces  a  series  of  original  articles  written  by  some 
sixty  well-known  psediatrists,  representing  collectively  the  teachings  of  the  most 
prominent  medical  schools  and  colleges  of  America.  The  work  is  intended  to 
be  a  PRACTICAL  book,  suitable  for  constant  and  handy  reference  by  the  practi- 
tioner and  the  a'dvanced  student. 

Especial  attention  has  been  given  to  the  latest  accepted  teachings  upon  the 
etiology,  symptoms,  pathology,  diagnosis,  and  treatment  of  the  disorders  of  chil- 
dren, with  the  introduction  of  many  special  formulae  and  therapeutic  procedures. 

In  this  new  edition  the  whole  subject  matter  has  been  carefully  revised,  new 
articles  added,  some  original  papers  emended,  and  a  number  entirely  rewritten. 
The  new  articles  include  "Modified  Milk  and  Percentage  Milk-Mixtures," 
"  Lithemia,"  and  a  section  on  "  Orthopedics."  Those  rewritten  are  "  Typhoid 
Fever,"  "Rubella,"  "Chicken-pox,"  "Tuberculous  Meningitis,"  "  Hydroceph- 
alus,"  and  "Scurvy;"  while  extensive  revision  has  been  made  in  "Infant 
Feeding,"  "  Measles,"  "  Diphtheria,"  and  "  Cretinism."  The  volume  has  thus 
been  much  increased  in  size  by  the  introduction  of  fresh  material. 

CONTRIBUTORS  I 


Dr.  S.  S.  Adams,  Washington. 

John  Ashhurst,  Jr.,  Philadelphia. 
A.  D.  Blackader,  Montreal,  Canada. 
David  Bovaird,  New  York. 
Dillon  Brown,  New  York. 
Edward  M.  Buckingham,  Boston. 
Charles  W.  Burr,  Philadelphia. 
W.  E.  Casselberry,  Chicago. 
Henry  Dwight  Chapin,  New  York. 
W.  S.  Christopher,  Chicago. 
Archibald  Church,  Chicago. 
Floyd  M.  Crandall,  New  York. 
Andrew  F.  Currier,  New  York. 
Roland  G.  Curtin,  Philadelphia 
J.  M.  DaCos'a,  Philadelphia. 
I.  N.  Danforth,  Chicago. 
Edward  P.  Davis,  Philadelphia. 
John  B.  Deaver,  Philadelphia. 
G.  E.  de  Schweirtitz,  Philadelphia. 
John  Doming,  New  York. 
Charles  Warrington  Earle,  Chicago. 
Wm.  A.  Edwards,  San  Diego,  Cal. 
F.  Forchheimer,  Cincinnati. 
I.  Henry  Fruitnight,  New  York. 
J.  P.  Crozer  Griffith,  Philadelphia. 
W.  A.  Hardaway.  St.  Louis. 
M.  P    Hatfield,  Chicago. 
Barton  Cooke  Hirst,  Philadelphia. 
H.  Illoway,  Cincinnati. 
Henry  Jackson,  Boston. 
Charles  G.  Jennings,  Detroit. 
Henry  Koplik,  New  York. 


Dr.  Thomas  S.  Latimer,  Baltimore. 
Albert  R.  Leeds,  Hoboken,  N.  J. 
J.  Hendrie  Lloyd,  Philadelphia. 
George  Roe  Lockwood,  New  York. 
Henry  M.  Lyman,  Chicago. 
Francis  T.  Miles,  Baltimore. 
Charles  K    Mills,  Philadelphia. 
James  E    Moore,  Minneapolis. 
F.  Gordon  Morrill,  Boston. 
John  H.  Musser,  Philadelphia. 
Thomas  R.  Neilson,  Philadelphia. 
W.  P.  Northrup,  New  York. 
William  Osier,  Baltimore. 
Frederick  A.  Packard,  Philadelphia. 
William  Pepper,  Philadelphia. 
Frederick  Peterson,  New  York. 
W.  T.  Plant,  Syracuse,  New  York 
William  M.  Powell.  Atlantic  City. 
B.  K.  Rachford,  Cincinnati. 
B.  Alexander  Randall,  Philadelphia 
Edward  O.  Shakespeare,  Philadtlplut 
F.  C.  Shattuck,  Boston. 
J.  Lewis  Smith,  New  York. 
Louis  Starr,  Philadelphia. 
M.  Allen  Starr,  New  York. 
Charles  W.  Townsend,  Boston. 
James  Tyson,  Philadelphia. 
W.  S.  Thayer,  Baltimore. 
Victor  C.  Vaughan,  Ann  Arbor,  Mich 
Thompson  S.  Westcolt,  Philadelphia. 
Henry  R.  Wharton,  Philadelphia. 
J    William  White,  Philadelphia. 
J.  C.  Wilson,  Philadelphia. 


12 


W.    B.    SAUNDERS' 


*AN  AMERICAN  TEXT-BOOK  OF  GENITO-URINARY  AND 
SKIN  DISEASES.  By  47  Eminent  Specialists  and  Teachers.  Edited 
by  L.  BOLTON  BANGS,  M.  D.,  Professor  of  Genito-Urinary  Surgery,  Uni- 
versity and  Bellevue  Hospital  Medical  College,  New  York;  and  W.  A. 
HARDAWAY,  M.  D.,  Professor  of  Diseases  of  the  Skin,  Missouri  Medical 
College.  Imperial  octavo  volume  of  1229  pages,  with  300  engravings  and 
20  full-page  colored  plates.  Cloth,  $7.00  net;  Sheep  or  Half  Morocco, 
$8.00  net. 

This  addition  to  the  series  of  "  American  Text-Books,"  it  is  confidently  be- 
lieved, will  meet  the  requirements  of  both  students  and  practitioners,  giving,  as 
it  does,  a  comprehensive  and  detailed  presentation  of  the  Diseases  of  the 
Genito-Urinary  Organs,  of  the  Venereal  Diseases,  and  of  the  Affections  of  the 
Skin. 

Having  secured  the  collaboration  of  well-known  authorities  in  the  branches 
represented  in  the  undertaking,  the  editors  have  not  restricted  the  contributors 
iu  regard  to  the  particular  views  set  forth,  but  have  offered  every  facility  for  the 
free  expression  of  their  individual  opinions.  The  work  will  therefore  be  found 
to  be  original,  yet  homogeneous  and  fully  representative  of  the  several  depart- 
ments of  medical  science  with  which  it  is  concerned. 


CONTRIBUTORS : 


Dr.  Chas.  W.  Allen,  New  York. 
I.  E.  Atkinson,  Baltimore. 
L   Bolton  Bangs,  New  York. 
P.  R.  Bolton,  New  York. 
Lewis  C.  Bosher,  Richmond,  Va. 
John  T.  Bowen,  Boston. 
J.  Abbott  Cantrell.  Philadelphia. 
William  T.  Corlett,  Cleveland,  Ohio. 
B.  Farquhar  Curtis,  New  York. 
Condict  W.  Cutler,  New  York. 
Isadore  Dyer,  New  Orleans. 
Christian  Fenger,  Chicago. 
John  A.  Fordyce,  New  York. 
Eugene  Fuller,  New  York. 
R.  H.  Greene,  New  York. 
Joseph  Grindon,  St.  Louis. 
Graeme  M.  Hammond,  New  York. 
W.  A.  Hardaway,  St.  Louis. 
M.  B.  Hartzell,  Philadelphia. 
Louis  Heitzmann,  New  York. 
James  S.  Howe,  Boston. 
George  T.  Jackson,  New  York. 
Abraham  Jacob! ,  New  York. 
James  C.  Johnston,  New  York. 


Dr.  Hermann  G.  Klotz,  New  York. 
J.  H.  Linsley,  Burlington,  Vt. 
G.  F.  Lydston,  Chicago. 
Hartwell  N.  Lyon,  St.  Louis. 
Edward  Martin,  Philadelphia. 
D.  G.  Montgomery,  San  Francisco. 
James  Pedersen,  New  York. 
S.  Pollitzer,  New  York. 
Thomas  R.  Pooley,  New  York. 
A.  R.  Robinson,  New  York. 
A.  E.  Rtgensburger,  San  Francisco. 
Francis  J.  Shepherd,  Montreal,  Can. 
S.  C.  Stanton,  Chicago,  111. 
Emmanuel  J.  Stout.  Philadelphia. 
Alonzo  E.  Taylor   Philadelphia. 
Robert  W.  Taylor,  New  York. 
Paul  Thorndike,  Boston. 
H.  Tuholske,  St.  Louis. 
Arthur  Van  Harlingen,  Philadelphia. 
Francis  S.  Watson,  Boston. 
J.  William  White,  Philadelphia. 
J.  McF.  Winfield,  Brooklyn. 
Alfred  C.  Wood,  Philadelphia. 


"This  voluminous  work  is  thoroughly  up  to  date,  and  the  chapters  on  genito-urinary  dis- 
eases are  especially  valuable.  The  illustrations  are  fine  and  are  mostly  original.  Ihe  section 
on  dermatology  is  concise  and  in  every  way  admirable."— Journal  of  the  American  Medical 
Association. 

"This  volume  is  one  of  the  best  yet  issued  of  the  publisher's  series  of  'American  Text- 
Books.'  The  list  of  contributors  represents  an  extraordinary  array  of  talent  and  extended 
experience.  The  book  will  easily  take  the  place  in  comprehensiveness  and  value  of  the 
half  dozen  or  more  costly  works  on  these  subjects  which  have  hitherto  been  necessary  to  a 
well-equipped  library." — New  York  Polyclinic. 


CATALOGUE    OF  MEDICAL    WORKS. 


*  AN  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  THE  EYE, 
EAR,  NOSE,  AND  THROAT.   Edited  by  GEORGE  E.  DE  SCHWEINITZ, 

A.  M.,  M.  D.,  Professor  of  Ophthalmology,  Jefferson  Medical  College;  and 

B.  ALEXANDER  RANDALL,  A.  M.,  M.  D.,  Clinical  Professor  of  Diseases  of 
the   Ear,   University    of  Pennsylvania.     One   handsome    imperial   octavo 
volume  of   1251   pages;    766  illustrations,  59  of  them  colored.     Prices: 
Cloth,  $7.00  net ;  Sheep  or  Half-Morocco,  $8.00  net. 

Just  Issued. 

The  present  work  is  the  only  book  ever  published  embracing  diseases  of  the 
intimately  related  organs  of  the  eye,  ear,  nose,  and  throat.  Its  special  claim 
to  favor  is  based  on  encyclopedic,  authoritative,  and  practical  treatment  of  the 
subjects. 

Each  section  of  the  book  has  been  entrusted  to  an  author  who  is  specially 
identified  with  the  subject  on  which  he  writes,  and  who  therefore  presents  his 
case  in  the  manner  of  an  expert.  Uniformity  is  secured  and  overlapping  pre- 
vented by  careful  editing  and  by  a  system  of  cross-references  which  forms  a 
special  feature  of  the  volume,  enabling  the  reader  to  come  into  touch  with  all 
that  is  said  on  any  subject  in  different  portions  of  the  book. 

Particular  emphasis  is  laid  on  the  most  approved  methods  of  treatment,  so 
that  the  book  shall  be  one  to  which  the  student  and  practitioner  can  refer  for 
information  in  practical  work.  Anatomical  and  physiological  problems,  also, 
are  fully  discussed  for  the  benefit  of  those  who  desire  to  investigate  the  more 
abstruse  problems  of  the  subject. 


CONTRIBUTORS : 


Dr.  Henry  A.  Alderton,  Brooklyn. 
Harrison  Allen,  Philadelphia. 
Frank  Allpori,  Chicago. 
Morris  J.  Asch.  New  York. 
S.  C.  Ayres,  Cincinnati. 
R.  O.  Beard,  Minn-apolis. 
Clarence  J.  Blake,  Boston. 
Arthur  A    Bliss,  Philadelphia. 
Albert  P.  Brubaker,  Philadelphia. 
J.  H.  Bryan,  Washington,  D.  C. 
Albert  H.  Buck,  New  York. 
F.  Buller,  Montreal,  Can. 
Swan  M.  Burnett,  Washington,  D   C. 
Flemming  Carrow,  Ann  Arbor,  Mich. 
W.  E.  Casselberry,  Chicago. 
Oilman  W.  Cutler,  New  York. 
Eil ward  B.  Dench,  New  York 
William  S.  Dennett.  New  York. 
George  E.  de  Schweinitz,  Philadelphia. 
Alexander  Duane,  New  York. 
John  W.  Farlow,  Boston,  Mass. 
Walter  J    Freeman,  Philadelphia. 
H.Gifford,  Omaha,  Neb. 
W.  C.  Glasgow,  St.  Louis. 
J.  Orne  Green,  Boston. 
Ward  A.  Holden,  New  York. 
Christian  R.  Holmes,  Cincinnati. 
William  E.  Hopkins,  San  Francisco. 
F.  C.  Hotz,  Chicago. 
Lucien  Howe,  Buffalo,  N.  Y. 


Dr.  Alvin  A.  Hubbell,  Buffalo,  N.  Y. 
Edward  Jackson,  Philadelphia. 
J.  Ellis  Jennings,  St.  Louis. 
Herman  Knapp,  New  York. 
Chas.  W.  Kollock,  Charleston,  S.  C. 
G.  A.  Leland,  Boston. 
J   A.  Lippiocott,  Pittsburg,  Pa. 
G.  Hudson  Makuen,  Philadelphia. 
John  H.  McCollom,  Boston. 
H.  G.  Miller,  Providence,  R.  I. 
B    L.  Milliken,  Cleveland,  Ohio. 
Robert  C.  Myles,  New  York. 
James  E.  Newcomb,  New  York. 
R.  J.  Phillips,  Philadelphia. 
George  A.  Piersol,  Philadelphia. 
W.  P.  Porcher,  Charleston.  S.  C. 
B.  Alex.  Randall,  Philadelphia. 
Robert  L.  Randolph,  Baltimore. 
John  O.  Roe,  Rochester,  N.  Y. 
Charles  E.  de  M.  Sajous,  Philadelphia. 
T.  E.  Sheppard,  Brooklyn,  N.  Y. 
E.  L.  Shurly.  Detroit,  Mich. 
William  M.  Sweet,  Philadelphia. 
Samuel  Theobald.  Baltimore,  Md. 
A.  G.  Thomson,  Philadelphia. 
Clarence  A.  Veasey,  Philadelphia. 
John  E.  Weeks,  New  York. 
Casey  A.  Wood,  Chicago,  111. 
Jonathan  Wright,  Brooklyn. 
H.  V.  Wiirdemann,  Milwaukee,  Wis. 


W.   B.    SAUNDERS' 


*AN  AMERICAN  YEAR-BOOK  OF  MEDICINE  AND  SUR- 
GERY. A  Yearly  Digest  of  Scientific  Progress  and  Authoritative 
Opinion  in  all  branches  of  Medicine  and  Surgery,  drawn  from  journals, 
monographs,  and  text-books  of  the  leading  American  and  Foreign  authors 
and  investigators.  Collected  and  arranged,  with  critical  editorial  com- 
ments, by  eminent  American  specialists  and  teachers,  under  the  general 
editorial  charge  of  GEORGE  M.  GOULD,  M.D.  One  handsome  imperial 
octavo  volume  of  about  1200  pages.  Uniform  in  style,  size,  and  general 
make-up  with  the  "American  Text-Book"  Series.  Cloth,  $6.50  net; 
Half-Morocco,  $7.50  net. 

Noiv  Ready,  Volumes  for  1896,  1897,  1898,  1899. 

Notwithstanding  the  rapid  multiplication  of  medical  and  surgical  works,  still 
these  publications  fail  to  meet  fully  the  requirements  of  the  general  physician, 
inasmuch  as  he  feels  the  need  of  something  more  than  mere  text-books  of  well- 
known  principles  of  medical  science. 

This  deficiency  would  best  be  met  by  current  journalistic  literature,  but  most 
practitioners  have  scant  access  to  this  almost  unlimited  source  of  information, 
and  the  busy  practiser  has  but  little  time  to  search  out  in  periodicals  the  many 
interesting  cases  whose  study  would  doubtless  be  of  inestimable  value  in  his 
practice.  Therefore,  a  work  which  places  before  the  physician  in  convenient 
form  an  epitomization  of  this  literature  by  persons  competent  to  pronounce  upon 

The  Value  of  a  Discovery  or  of  a  Method  of  Treatment 

cannot  but  command  his  highest  appreciation.  It  is  this  critical  and  judicial 
function  that  is  assumed  by  the  Editorial  staff  of  the  "  American  Year-Book 
of  Medicine  and  Surgery." 

CONTRIBUTORS : 


Dr.  Samuel  W.  Abbott.  Boston. 
John  I.  Abel,  Baltimore. 
J.  M.  Baldy,  Philadelphia. 
Charles  H.  Burnett,  Philadelphia. 
Archibald  Church,  Chicago 
J.  Chalmers  DaCosta,  Philadelphia. 
W.  A.  N.  Dorland,  Philadelphia. 
Louis  A.  Duhring,  Philadelphia. 
D.  L.  Edsall,  Philadelphia. 
Virgil  P.  Gibney,  New  York. 
Henry  A.  Griffin,  New  York. 
John  Guiteras,  Philadelphia. 
C.  A.  Hamann,  Cleveland. 
Alfred  Hand,  Jr.,  Philadelphia. 


Dr.  Howard  E.  Hansell,  Philadelphia. 
M.  B.  Hartzell,  Philadelphia. 
Barton  Cooke  Hirst,  Philadelphia. 
E.  Fletcher  Ir.gals,  Chicago. 
Wyatt  Johnston,  Montreal. 
W.  W.  Keen,  Philadelphia. 
Henry  G.  Ohls,  Chicago. 
Wendell  Reber,  Philadelphia. 
David  Riesman,  Philadelphia. 
Louis  Starr,  Philadelphia. 
Alfred  Stengel,  Philadelphia. 
G.  N.  Stewart.  Cleveland. 
J.  R.  Tillinghast,  New  York. 
J.  Hilton  Waterman,  New  York. 


"  It  is  difficult  to  know  which  to  admire  most — the  research  and  industry  of  the  distin- 
guished band  of  experts  whom  Dr.  Gould  has  enlisted  in  the  service  of  the  Year-Book,  or  the 
wealth  and  abundance  of  the  contributions  to  every  department  of  science  that  have  been 
deemed  worthy  of  analysis.  ...  It  is  much  more  than  a  mere  compilation  of  abstracts,  for, 
as  each  section  is  entrusted  to  experienced  and  able  contributors,  the  reader  has  the  advan- 
tage of  certain  critical  commentaries  and  expositions  .  .  .  proceeding  from  writers  fully 
qualified  to  perform  these  tasks.  ...  It  is  emphatically  a  book  which  should  find  a  place  in 
every  medical  library,  and  is  in  several  respects  more  useful  than  the  famous  '  Jahrbiicher' 
of  Germany." — London  Lancet. 


CATALOGUE    OF  MEDICAL    WORKS.  15 

*  ANOMALIES  AND  CURIOSITIES  OF  MEDICINE.  By  GEORGE 
M.  GOULD,  M.D.,  and  WALTER  L.  PYLE,  M.D.  An  encyclopedic  collec- 
tion of  are  and  extraordinary  cases  and  of  the  most  striking  instances  of 
abnormality  in  all  branches  of  Medicine  and  Surgery,  derived  from  an  ex- 
haustive research  of  medical  literature  from  its  origin  to  the  present  day, 
abstracted,  classified,  annotated,  and  indexed.  Handsome  imperial  octavo 
volume  of  968  pages,  with  295  engravings  in  the  text,  and  12  full-page 
plates.  Cloth,  $6.00  net ;  Half-Morocco,  $7.00  net. 

Several  years  of  exhaustive  research  have  been  spent  by  the  authors  in  the 
great  medical  libraries  of  the  United  States  and  Europe  in  collecting  the  mate- 
rial for  this  work.  Medical  literature  of  all  ages  and  all  languages  has 
been  carefully  searched,  as  a  glance  at  the  Bibliographic  Index  will  show.  The 
facts,  which  will  be  of  extreme  value  to  the  author  and  lecturer,  have  been 
arranged  and  annotated,  and  full  reference  footnotes  given,  indicating  whence 
they  have  been  obtained. 

In  view  of  the  persistent  and  dominant  interest  in  the  anomalous  and  curious, 
a  thorough  and  systematic  collection  of  this  kind  (the  first  of  which  the 
authors  have  knowledge)  must  have  its  own  peculiar  sphere  of  usefulness. 

As  a  complete  and  authoritative  Book  of  Reference  it  will  be  of  value  not 
only  to  members  of  the  medical  profession,  but  to  all  persons  interested  in  gen- 
eral scientific,  sociologic,  and  medico-legal  topics ;  in  fact,  the  general  interest 
of  the  subject  and  the  dearth  of  any  complete  work  upon  it  make  this  volume 
one  of  the  most  important  literary  innovations  of  the  day. 

"  One  of  the  most  valuable  contributions  ever  made  to  medical  literature.  It  is,  so  far  as 
we  know,  absolutely  unique,  and  every  page  is  as  fascinating  as  a  novel.  Not  alone  for  the 
medical  profession  has  this  volume  value  :  it  will  serve  as  a  book  of  reference  for  all  who  are 
interested  in  general  scientific,  sociologic,  or  medico-legal  topics." — Brooklyn  Medical  Jour- 
nal. 

NERVOUS  AND  MENTAL  DISEASES.  By  ARCHIBALD  CHURCH, 
M.  D.,  Professor  of  Clinical  Neurology,  Mental  Diseases,  and  Medical 
Jurisprudence,  Northwestern  University  Medical  School ;  and  FREDERICK 
PETERSON,  M.  D.,  Clinical  Professor  of  Mental  Diseases,  Woman's  Medi- 
cal College,  New  York.  Handsome  octavo  volume  of  843  pages,  with 
over  300  illustrations.  Prices:  Cloth,  $5.00  net;  Half- Morocco,  $6.00 
net. 

Just  Issued. 

This  book  is  intended  to  furnish  students  and  practitioners  with  a  practical, 
working  knowledge  of  nervous  and  mental  diseases.  Written  by  men  of  wide 
experience  and  authority,  it  presents  the  many  recent  additions  to  the  subject. 
The  book  is  not  filled  wilh  an  extended  dissertation  on  anatomy  and  pathology, 
but,  treating  these  points  in  connection  with  special  conditions,  it  lays  particular 
stress  on  methods  of  examination,  diagnosis,  and  treatment.  In  this  respect  the 
work  is  unusually  complete  and  valuable,  laying  down  the  definite  courses  of 
procedure  which  the  authors  have  found  to  be  most  generally  satisfactory. 


1 6  W.   B.   SAUNDERS 


A  TEXT-BOOK  OF  PATHOLOGY.  By  ALFRED  STENGEL,  M.  D., 
Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania;  Physi- 
cian to  the  Philadelphia  Hospital ;  Physician  to  the  Children's  Hospital, 
Philadelphia.  Handsome  octavo  volume  of  848  pages,  with  362  illustra- 
tions, many  of  which  are  in  colors.  Prices :  Cloth,  $4.00  net ;  Half- 
Morocco,  $5.00  net. 

Second  Edition. 

In  this  work  the  practical  application  of  pathological  facts  to  clinical  medicine 
is  considered  more  fully  than  is  customary  in  works  on  pathology.  While  the 
subject  of  pathology  is  treated  in  the  broadest  way  consistent  with  the  size  of 
the  book,  an  effort  has  been  made  to  present  the  subject  from  the  point  of  view 
of  the  clinician.  The  general  relations  of  bacteriology  to  pathology  are  dis- 
cussed at  considerable  length,  as  the  importance  of  these  branches  deserves.  It 
will  be  found  that  the  recent  knowledge  is  fully  considered,  as  well  as  older  and 
more  widely-known  facts. 

"  I  consider  the  work  abreast  of  modern  pathology,  and  useful  to  both  students  and  prac- 
titioners. It  presents  in  a  concise  and  well-considered  form  the  essential  facts  of  general  and 
special  pathological  anatomy,  with  more  than  usual  emphasis  upon  pathological  physiology." 
— WILLIAM  H.  WELCH,  Professor  of  Pathology,  Johns  Hopkins  University,  Baltimore,  Md. 

"  I  regard  it  as  the  most  serviceable  text-book  for  students  on  this  subject  yet  written  by 
an  American  author." — L.  HEKTOEN,  Professor  of  Pathology,  Rush  Medical  College, 
Chicago,  III. 

A  TEXT-BOOK  OF  OBSTETRICS.  By  BARTON  COOKE  HIRST,  M.D., 
Professor  of  Obstetrics  in  the  University  of  Pennsylvania.  Handsome  oc- 
tavo volume  of  846  pages,  with  618  illustrations  and  seven  colored  plates. 
Prices:  Cloth,  $5.00  net;  Half- Morocco,  $6.00  net. 

This  work,  which  has  been  in  course  of  preparation  for  several  years,  is  in- 
tended as  an  ideal  text-book  for  the  student  no  less  than  an  advanced  treatise 
for  the  obstetrician  and  for  general  practitioners.  It  represents  the  very  latest 
teaching  in  the  practice  of  obstetrics  by  a  man  of  extended  experience  and 
recognized  authority.  The  book  emphasizes  especially,  as  a  work  on  obstetrics 
should,  the  practical  side  of  the  subject,  and  to  this  end  presents  an  unusually 
large  collection  of  illustrations.  A  great  number  of  these  are  new  and  original, 
and  the  whole  collection  will  form  a  complete  atlas  of  obstetrical  practice. 
An  extremely  valuable  feature  of  the  book  is  the  large  number  of  refer- 
ences to  cases,  authorities,  sources,  etc.,  forming,  as  it  does,  a  valuable  bib- 
liography of  the  most  recent  and  authoritative  literature  on  the  subject 
of  obstetrics.  As  already  stated,  this  work  records  the  wide  practical  ex- 
perience of  the  author,  which  fact,  combined  with  the  brilliant  presentation 
of  the  subject,  will  doubtless  render  this  one  of  the  most  notable  books  on 
obstetrics  that  has  yet  appeared. 

"  The  illustrations  are  numerous  and  are  works  of  art,  many  of  them  appearing  for  the 
first  time.  The  arrangement  of  the  subject-matter,  the  foot-notes,  and  index  are  beyond 
criticism.  The  author's  style,  though  condensed,  is  singularly  cle.ir.  so  that  it  is  never 
necessary  to  re-read  a  sentence  in  order  to  grasp  its  meaning.  As  a  true  model  of  what  a 
modern  text-book  in  obstetrics  should  be,  we  feel  justified  in  affirming  that  Dr.  Hirst's 
book  is  without  a  rival." — New  )'ork  Medical  R.-csrd. 


CATALOGUE    OF  MEDICAL    WORKS. 


A    TEXT-BOOK    OF    THE    PRACTICE    OF    MEDICINE.      By 

JAMES  M.  ANDERS,  M.D.,  PH.D.,  LL.D.,  Professor  of  the  Practice  of 
Medicine  and  of  Clinical  Medicine,  Medico-Chirurgical  College,  Philadel- 
phia. In  one  handsome  octavo  volume  of  1292  pages,  fully  illustrated. 
Cloth,  $5.50  net;  Sheep  or  Half-  Morocco,  $6.50  net. 

THIRD   EDITION,  THOROUGHLY   REVISED. 

The  present  edition  is  the  result  of  a  careful  and  thorough  revision.  A  few 
new  subjects  have  been  introduced  :  Glandular  Fever,  Ether-pneumonia,  Splenic 
Anemia,  Meralgia  Paresthetica,  and  Periodic  Paralysis.  The  affections  that 
have  been  substantially  rewritten  are:  Plague,  Malta  Fever,  Diseases  of  the 
Thymus  Gland,  Liver  Cirrhoses,  and  Progressive  Spinal  Muscular  Atrophy. 
The  following  articles  have  been  extensively  revised  :  Typhoid  Fever,  Yellow 
Fever,  Lobar  Pneumonia,  Dengue,  Tuberculosis,  Diabetes  Mellitus,  Gout,  Ar- 
thritis Deformans,  Autumnal  Catarrh,  Diseases  of  the  Circulatory  System,  more 
particularly  Hypertrophy  and  Dilatation  of  the  Heart,  Arteriosclerosis  and 
Thoracic  Aneurysm,  Pancreatic  Hemorrhage,  Jaundice,  Acute  Peritonitis,  Acute 
Yellow  Atrophy,  Hematoma  of  Dura  Mater,  and  Scleroses  of  the  Brain.  The 
preliminary  chapter  on  Nervous  Diseases  is  new,  and  deals  with  the  subject  of 
localization  and  the  various  methods  of  investigating  nervous  affections. 

"  It  is  an  excellent  book—  concise,  comprehensive,  thorough,  and  up  to  date.  It  is  a 
credit  to  you;  but,  more  than  that,  it  is  a  credit  to  the  profession  of  Philadelphia  —  to  us." 
—JAMES  C.  WILSON,  Professor  of  the  Practice  of  Medicine  and  Clinical  Medicine,  Jeffer- 
son Medical  College,  Philadelphia. 

"I  consider  Dr.  Anders'  book  not  only  the  best  late  work  on  Medical  Practice,  but  by  far 
the  best  that  has  ever  been  published.  It  is  concise,  systematic,  thorough,  and  fully  up  to 
date  in  everything.  I  consider  it  a  great  credit  to  both  the  author  and  the  publisher."  —  A. 
C.  COWPERTHWAITE,  President  of  the  Illinois  Homeopathic  Medical  Association. 

DISEASES  OF  THE  STOMACH.  By  WILLIAM  W.  VAN  VAT.ZAH, 
M.  D.,  Professor  of  General  Medicine  and  Diseases  of  the  Digestive  System 
and  the  Blood,  New  York  Polyclinic  ;  and  J.  DOUGLAS  NISBET,  M.  D., 
Adjunct  Professor  of  General  Medicine  and  Diseases  of  the  Digestive  Sys- 
tem and  the  Blood,  New  York  Polyclinic.  Octavo  volume  of  674  pages, 
illustrated.  Cloth,  $3.50  net. 

An  eminently  practical  book,  intended  as  a  guide  to  the  student,  an  aid  to  the 
physician,  and  a  contribution  to  scientific  medicine.  It  aims  to  give  a  complete 
description  of  the  modern  methods  of  diagnosis  and  treatment  of  diseases  of  the 
stomach,  and  to  reconstruct  the  pathology  of  the  stomach  in  keeping  with  the 
revelations  of  scientific  research.  The  book  is  clear,  practical,  and  complete, 
and  contains  the  results  of  the  authors'  investigations  and  of  their  extensive  ex- 
perience as  specialists.  Particular  attention  is  given  to  the  important  subject  of 
dietetic  treatment.  The  diet-lists  are  very  complete,  and  are  so  arranged  that 
selections  can  readily  be  made  to  suit  individual  cases. 

"This  is  the  most  satisfactory  work  on  the  subject  in  the  English  language."  —  Chicago 
Medical  Recorder. 

"  The  article  on  diet  and  general  medication  is  one  of  the  most  valuable  in  the  book,  and 
should  be  read  by  every  practising  physician."  —  New  York  Medical  Journal. 


1 8  W.   B.   SAUNDERS* 


SURGICAL  DIAGNOSIS   AND    TREATMENT.     By   J.  W.    MAC- 
DONALD,  M.  D.,  Edin.,  F.  R.  C.  S.,  Edin.,  Professor  of  the  Practice  of  Sur- 
gery and  of  Clinical  Surgery  in  Hamline  University ;  Visiting  Surgeon  to  St. 
Barnabas'  Hospital,  Minneapolis,  etc.     Handsome  octavo  volume  of  800 
pages,  profusely  illustrated.     Cloth,  $5.00  net;  Half-Morocco,  $6.00  net. 
This  work  aims  in  a  comprehensive  manner  to  furnish  a  guide  in  matters  of 
surgical  diagnosis.     It  sets  forth  in  a  systematic  way  the  necessities  of  examina- 
tions and  the  proper  methods  of  making  them.     The  various  portions  of  the 
body  are  then  taken  up  in  order  and  the  diseases  and  injuries  thereof  succinctly 
considered  and  the  treatment  briefly  indicated.     Practically  all  the  modem  and 
approved  operations  are  described  with  thoroughness  and  clearness.     The  work 
concludes  with  a  chapter  on  the  use  of  the  Rontgen  rays  in  surgery. 

"The  work  is  brimful  of  just  the  kind  of  practical  information  that  is  useful  alike  to 
students  and  practitioners.  It  is  a  pleasure  to  commend  the  book  because  of  its  intrinsic 
value  to  the  medical  practitioner." — Cincinnati  Lancet-Clinic. 

PATHOLOGICAL  TECHNIQUE.     A  Practical  Manual  for  Laboratory 
Work  in  Pathology,  Bacteriology,  and  Morbid  Anatomy,  with  chapters  on 
Post-Mortem  Technique  and  the  Performance  of  Autopsies.     By  FRANK 
B.  MALLORY,  A.  M.,  M.  D.,  Assistant  Professor  of  Pathology,  Harvard 
University  Medical  School,  Boston ;  and  JAMES  H.  WRIGHT,  A.  M.,  M.  D., 
Instructor  in  Pathology,  Harvard  University  Medical  School,  Boston.     Oc- 
tavo volume  of  396  pages,  handsomely  illustrated.     Cloth,  $2.50  net. 
This  book  is  designed  especially  for  practical  use  in  pathological  laboratories, 
both  as  a  guide  to  beginners  and  as  a  source  of  reference  for  the  advanced.   The 
book  will  also  meet  the  wants  of  practitioners  who  have  opportunity  to  do  general 
pathological  work.     Besides  the  methods  of  post-mortem  examinations  and  of 
bacteriological   and  histological   investigations   connected    with   autopsies,  the 
special  methods  employed  in  clinical  bacteriology  and  pathology  have  been 
fully  discussed. 

"  One  of  the  most  complete  works  on  the  subject,  and  one  which  should  be  in  the  library 
of  every  physician  who  hopes  to  keep  pace  with  the  great  advances  made  in  pathology."— 
Journal  of  American  Medical  Association. 

THE  SURGICAL  COMPLICATIONS  AND  SEQUELS  OF  TY- 
PHOID FEVER.     By  WM.  W.  KEEN,  M.  D.,  LL.D.,  Professor  of  the 
Principles  of  Surgery  and  of  Clinical  Surgery,  Jefferson  Medical  College, 
Philadelphia.     Octavo  volume  of  386  pages,  illustrated.     Cloth,  $3.00  net. 
This  monograph  is  the  only  one  in  any  language  covering  the  entire  subject 
of  the  Surgical  Complications  and  Sequels  of  Typhoid  Fever.     The  work  will 
prove  to  be  of  importance  and  interest  not  only  to  the  general  surgeon  and  phy- 
sician, but  also  to  many  specialists — laryngologists,  ophthalmologists,  gynecolo- 
gists, pathologists,  and  bacteriologists — as  the  subject  has  an  important  bearing 
upon  each  one  of  their  spheres.     The  author's  conclusions  are  based  on  reports 
of  over  1700  cases,  including  practically  all  those  recorded  in  the  last  fifty  years. 
Reports  of  cases  have  been  brought  down  to  date,  many  having  been  added 
while  the  work  was  in  press. 

"  This  is  probably  the  first  and  only  work  in  the  English  language  th.it  gives  the  reader  a 
clear  view  of  what  typhoid  fever  really  is,  and  what  it  does  and  can  do  to  the  human  organ- 
ism. This  book  should  be  in  the  possession  of  every  medical  man  in  America." — American 
Medico-Surgical  Bulletin. 


CATALOGUE    OF  MEDICAL    WORKS.  19 

MODERN  SURGERY,  GENERAL  AND  OPERATIVE.  By  JOHN 
CHALMERS  DACosTA,  M.D.,  Clinical  Professor  of  Surgery,  Jefferson  Medi- 
cal College,  Philadelphia;  Surgeon  to  the  Philadelphia  Hospital,  etc. 
Handsome  octavo  volume  of  911  pages,  profusely  illustrated.  Cloth,  $4.00 
net ;  Half- Morocco,  $5.00  net. 

Second  Edition,  Rewritten  and  Greatly  Enlarged. 

The  remarkable  success  attending  DaCosta's  Manual  of  Surgery,  and  the 
general  favor  with  which  it  has  been  received,  have  led  the  author  in  this 
revision  to  produce  a  complete  treatise  on  modern  surgery  along  the  same  lines 
that  made  the  former  edition  so  successful.  The  book  has  been  entirely  re- 
written and  very  much  enlarged.  The  old  edition  has  long  been  a  favorite  not 
only  with  students  and  teachers,  but  also  with  practising  physicians  and  sur- 
geons, and  it  is  believed  that  the  present  work  will  find  au  even  wider  field  of 
usefulness. 

"  We  know  of  no  small  work  on  surgery  in  the  English  language  which  so  well  fulfils  the 
requirements  of  the  modern  student." — Medico-Chirurgical  Journal,  Bristol,  England. 

"  The  author  has  presented  concisely  and  accurately  the  principles  of  modern  surgery. 
The  book  is  a  valuable  one  which  can  be  recommended  to  students  and  is  of  great  value  to 
the  general  practitioner." — American  Journal  of  the  Medical  Sciences. 

A  MANUAL  OF  ORTHOPEDIC  SURGERY.  By  JAMES  E.  MOORE, 
M.D.,  Professor  of  Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery, 
University  of  Minnesota,  College  of  Medicine  and  Surgeiy.  Octavo  volume 
of  356  pages,  with  177  beautiful  illustrations  from  photographs  made  spec- 
ially for  this  work.  Cloth,  $2.50  net. 

A  practical  book  based  upon  the  author's  experience,  in  which  special  stress 
is  laid  upon  early  diagnosis  and  treatment  such  as  can  be  carried  out  by  the 
general  practitioner.  The  teachings  of  the  author  are  in  accordance  with  his 
belief  that  true  conservatism  is  to  be  found  in  the  middle  course  between  the 
surgeon  who  operates  too  frequently  and  the  orthopedist  who  seldom  operates. 

"A  very  demonstrative  work,  every  illustration  of  which  conveys  a  lesson.  The  work  is 
a  most  excellent  and  commendable  one,  which  we  can  certainly  endorse  with  pleasure." — 
St.  Louis  Medical  and  Surgical  "Journal. 

ELEMENTARY   BANDAGING    AND    SURGICAL   DRESSING. 

With  Directions  concerning  the  Immediate  Treatment  of  Cases  of  Emer- 
gency. For  the  use  of  Dressers  and  Nurses.  By  WALTER  PYE,  F.R.C.S., 
late  Surgeon  to  St.  Mary's  Hospital,  London.  Small  I2mo,  with  over  80 
illustrations.  Cloth,  flexible  covers,  75  cents  net. 

This  little  book  is  chiefly  a  condensation  of  those  portions  of  Pye's  "  Surgical 
Handicraft"  which  deal  with  bandaging,  splinting,  etc.,  and  of  those  which 
treat  of  the  management  in  the  first  instance  of  cases  of  emergency.  The 
directions  given  are  thoroughly  practical,  and  the  book  will  prove  extremely  use- 
ful to  students,  surgical  nurses,  and  dressers. 

"The  author  writes  well,  the  diagrams  are  clear,  and  the  book  itself  is  small  and  portable, 
although  the  paper  and  type  are  good." — British  Medical  Journal. 


20  W.   B.   SAUNDERS1 


A  TEXT-BOOK  OF  MATERIA  MEDICA,  THERAPEUTICS 
AND  PHARMACOLOGY.  By  GEORGE  F.  BUTLER,  Pn.G.,  M.D., 
Professor  of  Materia  Medica  and  of  Clinical  Medicine  in  the  College  of 
Physicians  and  Surgeons,  Chicago;  Professor  of  Materia  Medica  and 
Therapeutics,  Northwestern  University,  Woman's  Medical  School,  etc. 
Octavo,  874  pages,  illustrated.  Cloth,  $4.00  net;  Sheep,  $5.00  net. 

Third  Edition,  Thoroughly  Kevised. 

A  clear,  concise,  and  practical  text-book,  adapted  for  permanent  reference  no 
less  than  for  the  requirements  of  the  class-room. 

The  recent  important  additions  made  to  our  knowledge  of  the  physiological 
action  of  drugs  are  fully  discussed  in  the  present  edition.  The  book  has  been 
thoroughly  revised  and  many  additions  have  been  made. 

"  Taken  as  a  whole,  the  book  may  fairly  be  considered  as  one  of  the  most  satisfactory  of  any 
single-volume  works  on  matena  mcdica  in  the  market."— Journal  of  the  American  Medical 
Association. 

TUBERCULOSIS  OF  THE  GENITO-URINARY  ORGANS, 
MALE  AND  FEMALE.  By  NICHOLAS  SENN,  M.D.,  PH.D.,  LL.D., 
Professor  of  the  Practice  of  Surgery  and  of  Clinical  Surgery,  Rush  Medical 
College,  Chicago.  Handsome  octavo  volume  of  320  pages,  illustrated 
Cloth,  $3.00  net. 

Tuberculosis  of  the  male  and  female  genito-urinary  organs  is  such  a  frequent, 
distressing,  and  fatal  affection  that  a  special  treatise  on  the  subject  appears  to 
fill  a  gap  in  medical  literature.  In  the  present  work  the  bacteriology  of  the  sub- 
ject has  received  clue  attention,  the  modern  resources  employed  in  the  difieren- 
tinl  diagnosis  between  tubercular  and  other  inflammatory  affections  are  fully 
described,  and  the  medical  and  surgical  therapeutics  are  discussed  in  detail. 

"An  important  bock  upon  an  important  subject,  and  written  by  a  man  of  mature  judg- 
ment and  wide  experience.  The  author  has  given  us  an  instructive  book  upon  one  of  the 
most  important  subjects  of  the  day." — Clinical  Reporter. 

"  A  work  which  adds  another  to  the  many  obligations  the  profession  owes  the  talented 
author." — Chicago  Medical  Recorder. 

A  TEXT-BOOK  OF  DISEASES  OF  WOMEN.  By  CHARLES  B. 
PENROSE,  M.D.,  PH.D.,  Professor  of  Gynecology  in  the  University  of 
Pennsylvania;  Surgeon  to  the  Gynecean  Hospital,  Philadelphia.  Octavo 
volume  of  529  pages,  with  217  illustrations,  nearly  all  from  drawings  made 
for  this  work.  Cloth,  $3.50  net. 

Second  Edition,  Revised. 

In  this  work,  which  has  been  written  for  both  the  student  of  gynecology  and 
the  general  practitioner,  the  author  presents  the  best  teaching  of  modern  gyne- 
cology untrammelled  by  antiquated  theories  or  methods  of  treatment.  In  most 
instances  but  one  plan  of  treatment  is  recommended,  to  avoid  confusing  the 
student  or  the  physician  who  consults  the  book  for  practical  guidance. 

"  I  shall  value  very  highly  the  copy  of  Penrose's  '  Diseases  of  Women '  received.  1  have 
already  recommended  it  to  my  class  as  THE  BF.ST  book." — HOWARD  A.  KELLY,  Professor 
of  Gynecology  and  Obstetrics,  Johns  Hopkins  University,  Baltimore,  Md. 

"  The  book  is  to  be  commended  without  reserve,  not  only  to  the  student  but  to  the  general 
practitioner  who  wishes  to  have  the  latest  and  best  modes  of  treatment  explained  with  absolute 
clearness." —  Therapeutic  Gazette. 


CATALOGUE    OF  MEDICAL    WORKS.  21 

SURGICAL  PATHOLOGY  AND  THERAPEUTICS.  By  JOHN 
COLLINS  WARREN,  M.  D.,  LL.D.,  Professor  of  Surgery,  Medical  Depart- 
ment Harvard  University;  Surgeon  to  the  Massachusetts  General  Hospital, 
etc.  A  handsome  octavo  volume  of  832  pages,  with  136  relief  and  litho- 
graphic illustrations,  33  of  which  are  printed  in  colors,  and  all  of  which 
were  drawn  by  William  J.  Kaula  from  original  specimens.  New  and  en- 
larged Edition  in  Preparation. 

Without   Exception,  the  Illustrations   are   the  Best  ever  Seen   in   a 
Work  of  this  Kind. 

"A  most  striking  and  very  excellent  feature  of  this  book  is  its  illustrations.  Without  ex- 
ception, from  the  point  of  accuracy  and  artistic  merit,  they  are  the  best  ever  seen  in  a  work 
of  this  kind.  *  *  *  Many  of  those  representing  microscopic  pictures  are  so  perfect  in  their 
coloring  anij  detail  as  almost  to  give  the  beholder  the  impression  that  he  is  looking  down  the 
barrel  of  a  microscope  at  a  well-mounted  section." — Annals  of  Surgery,  Philadelphia. 

"  It  is  the  handsomest  specimen  of  book-making  *  *  *  that  has  ever  been  issued  from  the 
American  medical  press." — American  Journal  of  the  Medical  Sciences,  Philadelphia. 

PATHOLOGY  AND   SURGICAL  TREATMENT   OF  TUMORS. 

By  N.  SENN,  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  Practice  of  Surgery  and 
of  Clinical  Surgery,  Rush  Medical  College;  Professor  of  Surgery,  Chicago 
Polyclinic ;  Attending  Surgeon  to  Presbyterian  Hospital ;  Surgeon-in-Chief, 
St.  Joseph's  Hospital,  Chicago.  One  volume  of  710  pages,  with  515 
engravings,  including  full-page  colored  plates.  New  and  enlarged  Edition 
in  Preparation. 

Books  specially  devoted  to  this  subject  are  few,  and  in  our  text-books  and 
systems  of  surgery  this  part  of  surgical  pathology  is  usually  condensed  to  a  de- 
gree incompatible  with  its  scientific  and  clinical  importance.  The  author  spent 
many  years  in  collecting  the  material  for  this  work,  and  has  taken  great  pains 
to  present  it  in  a  manner  that  should  prove  useful  as  a  text-book  for  the  student, 
a  work  of  reference  for  the  practitioner,  and  a  reliable  guide  for  the  surgeon. 

"  The  most  exhaustive  of  any  recent  book  in  English  on  this  subject.  It  is  well  illus- 
trated, and  will  doubtless  remnin  as  the  principal  monograph  on  the  subject  in  our  language 
for  some  years.  The  book  is  handsomely  illustrated  and  printed,  ....  and  the  author  has 
given  a  notable  and  lasting  contribution  to  surgery." — Journal  of  the  American  Medical 
Association,  Chicago. 

LECTURES    ON    RENAL    AND    URINARY     DISEASES.       By 

ROBERT  SAUNDBY,  M.  D.,  Edin.,  Fellow  of  the  Royal  College  of  Physicians, 
London,  and  of  the  Royal  Medico-Chirurgical  Society;  Physician  to  the 
General  Hospital.  Octavo  volume  of  434  pages,  with  numerous  illustra- 
tions and  4  colored  plates.  Cloth,  $2.50  net. 

"  The  volume  makes  a  favorable  impression  at  once.  The  style  is  clear  and  succinct. 
We  cannot  find  any  part  of  the  subject  in  wliich  the  views  expressed  are  not  carefully  thought 
out  and  fortified  by  evidence  drawn  from  the  most  recent  sources.  The  book  may  be  cordially 
recommended." — British  Medical  yoitrnal. 

"  The  work  represents  the  present  knowledge  of  renal  and  urinary  diseases.  It  is  ad- 
mirably written  and  is  accurately  scientific." — Medical  News. 


22  W.   B.   SAUNDERS* 


A  NEW  PRONOUNCING  DICTIONARY  OF  MEDICINE,  with 
Phonetic  Pronunciation,  Accentuation,  Etymology,  etc.  By  JOHN 
M.  KEATING,  M.  D.,  LL.D.,  Fellow  of  the  College  of  Physicians  of  Phila- 
delphia; Vice- President  of  the  American  Psediatric  Society;  Ex-President 
of  the  Association  of  Life  Insurance  Medical  Directors ;  Editor  "  Cyclo- 
paedia of  the  Diseases  of  Children,"  etc.;  and  HENRY  HAMILTON,  author 
of  "  A  New  Translation  of  Virgil's  ^Eneid  into  English  Rhyme ;"  co- 
author of  "  Saunders'  Medical  Lexicon,"  etc. ;  with  the  Collaboration  of 
J.  CHALMERS  DACOSTA,  M.  D.,  and  FREDERICK  A.  PACKARD,  M.  D. 
With  an  Appendix  containing  important  Tables  of  Bacilli,  Micrococci, 
Leucomaines,  Ptomaines,  Drugs  and  Materials  used  in  Antiseptic  Sur- 
gery, Poisons  and  their  Antidotes,  Weights  and  Measures,  Thermometric 
Scales,  New  Official  and  Unofficial  Drugs,  etc.  One  very  attractive  volume 
of  over  800  pages.  Second  Revised  Edition.  Prices:  Cloth,  $5.00  net; 
Sheep  or  Half-Morocco,  $6.00  net;  with  Denison's  Patent  Ready- Refer- 
ence Index ;  without  patent  index,  Cloth,  $4.00  net ;  Sheep  or  Half- 
Morocco,  $5.00  net. 

PROFESSIONAL,  OPINIONS. 

"  I  am  much  pleased  with  Keating's  Dictionary,  and  shall  take  pleasure  in  recommending 
it  to  my  classes." 

HBNKY  M.  LYMAN,  M.  D., 
Professor  of  Principles  and  Practice  of  Medicine,  Rush  Medical  College,  Chicago,  III. 

"  I  am  convinced  that  it  will  be  a  very  valuable  adjunct  to  my  study-table,  convenient  in 
size  and  sufficiently  full  for  ordinary  use." 

C.  A.  LINDSLEY,  M.  D., 
Professor  of  Theory  and  Practice  of  Medicine,  Medical  Dept.  Yale  University: 

Secretary  Connecticut  State  Board  of  Health,  New  Haven,  Conn, 

AUTOBIOGRAPHY  OF  SAMUEL  D.  GROSS,  M.  D.,  Emeritus  Pro- 
fessor of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia,  with 
Reminiscences  of  His  Times  and  Contemporaries.      Edited  by  his  sons, 
SAMUEL  W.  GROSS,  M.  D.,  LL.D.,  late  Professor  of  Principles  of  Surgery 
and  of  Clinical  Surgery  in  the  Jefferson  Medical  College,  and  A.  HALLER 
GROSS,  A.  M.,  of  the  Philadelphia  Bar.     Preceded  by  a  Memoir  of  Dr. 
Gross,  by  the  late  Austin  Flint,  M.  D.,  LL.D.     In  two  handsome  volumes, 
each  containing  over  400  pages,  demy  8vo,  extra  cloth,  gilt  tops,  with  fine 
Frontispiece  engraved  on  steel.    Price  per  Volume,  $2.50  net 
1  his  autobiography,  which  was  continued  by  the  late  eminent  surgeon  until 
within  three  months  of  his  death,  contains  a  full  and  accurate  history  of  his 
early  struggles,  trials,  and  subsequent  successes,  told  in  a  singularly  interesting 
and  charming  manner,  and  embraces  short  and  graphic  pen-portraits  of  many 
of  the  most  distinguished  men — surgeons,  physicians,  divines,  lawyers,  states- 
men, scientists,  etc. — with  whom  he  was  brought  in  contact  in  America  and  in 
Europe ;  the  whole  forming  a  retrospect  of  more  than  three-quarters  of  a  century. 


CATALOGUE    OF  MEDICAL    WORKS.  23 

PRACTICAL  POINTS  IN  NURSING.  For  Nurses  in  Private 
Practice.  By  EMILY  A.  M.  STONEY,  Graduate  of  the  Training-School 
for  Nurses,  Lawrence,  Mass. ;  Superintendent  of  the  Training-School  for 
Nurses,  Carney  Hospital,  South  Boston,  Mass.  456  pages,  handsomely 
illustrated  with  73  engravings  in  the  text,  and  9  colored  and  half-tone 
plates.  Cloth.  Price,  #1.75  net. 

SECOND  EDITION,  THOROUGHLY- BE  VISED. 

In  this  volume  the  author  explains,  in  popular  language  and  in  the  shortest 
possible  form,  the  entire  range  of  private  nursing  as  distinguished  from  hospital 
nursing,  and  the  nurse  is  instructed  how  best  to  meet  the  various  emergencies  of 
medical  and  surgical  cases  when  distant  from  medical  or  surgical  aid  or  when 
thrown  on  her  own  resources. 

An  especially  valuable  feature  of  the  work  will  be  found  in  the  directions  to 
the  nurse  how  to  improvise  everything  ordinarily  needed  in  the  sick-room,  where 
the  embarrassment  of  the  nurse,  owing  to  the  want  of  proper  appliances,  is  fre- 
quently extreme. 

The  work  has  been  logically  divided  into  the  following  sections : 

I.  The  Nurse :  her  responsibilities,  qualifications,  equipment,  etc. 
II.  The  Sick-Room :  its  selection,  preparation,  and  management. 
'II.  The  Patient :  duties  of  the  nurse  in  medical,  surgical,  obstetric,  and  gyne- 
cologic cases. 

IV.  Nursing  in  Accidents  and  Emergencies. 
V.  Nursing  in  Special  Medical  Cases. 
VI.  Nursing  of  the  New-born  and  Sick  Children. 
VII.  Physiology  and  Descriptive  Anatomy. 

The  APPENDIX  contains  much  information  in  compact  form  that  will  be  found 
of  great  value  to  the  nurse,  including  Rules  for  Feeding  the  Sick;  Recipes  for 
Invalid  Foods  and  Beverages;  Tables  of  Weights  and  Measures;  Table  for 
Computing  the  Date  of  Labor;  List  of  Abbreviations ;  Dose-List;  and  a  full 
and  complete  Glossary  of  Medical  Terms  and  Nursing  Treatment. 

"This  is  a  well-written,  eminently  practical  volume,  which  covers  the  entire  range  of 
private  nursing  as  distinguished  from  hospital  nursing,  and  instructs  the  nurse  how  best  to 
meet  the  various  emergencies  which  may  arise  and  how  to  prepare  everything  ordinarily 
needed  in  the  illness  of  her  patient." — American  Journal  of  Obstetrics  and  Diseases  of 
Women  and  Children,  Aug.,  1896. 

A  TEXT-BOOK  OF  BACTERIOLOGY,  including  the  Etiology  and 
Prevention  of  Infective  Diseases  and  an  account  of  Yeasts  and  Moulds, 
Haematozoa,  and  Psorosperms.  By  EDGAR  M.  CROOKSHANK,  M.  B.,  Pro- 
fessor of  Comparative  Pathology  and  Bacteriology,  King's  College,  London. 
A  handsome  octavo  volume  of  700  pages,  with  273  engravings  in  the  text, 
and  22  original  and  colored  plates.  Price,  $6.50  net. 

This  book,  though  nominally  a  Fourth  Edition  of  Professor  Crookshank's 
"  MANUAL  OF  BACTERIOLOGY,"  is  practically  a  new  work,  the  old  one  having 
been  reconstructed,  greatly  enlarged,  revised  throughout,  and  largely  rewritten, 
forming  a  text-book  for  the  Bacteriological  Laboratory,  for  Medical  Omcers  of 
Health,  and  for  Veterinary  Inspectors. 


24  W.  B.   SAUNDERS1 


MEDICAL  DIAGNOSIS.  By  Dr.  OSWALD  VIERORDT,  Professor  of 
Medicine  At  the  University  of  Heidelberg.  Translated,  with  additions, 
from  the  Fifth  Enlarged  German  Edition,  with  the  author's  permission,  by 
FRANCIS  H.  STUART,  A.  M.,  M.  D.  In  one  handsome  royal-octavo  volume 
of  600  pages.  194  fine  wood-cuts  in  the  text,  many  of  them  in  colors. 
Prices:  Cloth,  $4.00  net;  Sheep  or  Half-Morocco,  #5.00  net. 

FOURTH  AMERICAN  EDITION,  FROM  THE  FIFTH  REVISED  AND 
ENLARGED  GERMAN  EDITION. 

In  this  work,  as  in  no  other  hitherto  published,  are  given  full  and  accurate 
explanations  of  the  phenomena  observed  at  the  bedside.  It  is  distinctly  a  clin- 
ical work  by  a  master  teacher,  characterized  by  thoroughness,  fulness,  and  accu- 
racy. It  is  a  mine  of  information  upon  the  points  that  are  so  often  passed  over 
without  explanation.  Especial  attention  has  been  given  to  the  germ-theory  as  a 
factor  in  the  origin  of  disease. 

The  present  edition  of  this  highly  successful  work  has  been  translated  from 
the  fifth  German  edition.  Many  alterations  have  been  made  throughout  the 
book,  but  especially  in  the  sections  on  Gastric  Digestion  and  the  Nervous  System. 

It  will  be  found  that  all  the  qualities  which  served  to  make  the  earlier  editions 
so  acceptable  have  been  developed  with  the  evolution  of  the  work  to  its  present 
form. 

THE  PICTORIAL  ATLAS  OF  SKIN  DISEASES  AND  SYPHI- 
LITIC AFFECTIONS.  (American  Edition.)  Translation  from 
the  French.  Edited  by  J.  J.  PRINGLE,  M.  B.,  F.  R.  C.  P.,  Assistant  Phy- 
sician to,  and  Physician  to  the  department  for  Diseases  of  the  Skin  at,  the 
Middlesex  Hospital,  London.  Photo-lithochromes  from  the  famous  models 
of  dermatological  and  syphilitic  cases  in  the  Museum  of  the  Saint-Louis 
Hospital,  Paris,  with  explanatory  wood-cuts  and  letter-press.  In  12  Parts, 
at  $3-00  per  Part. 

"  Of  all  the  atlases  of  skin  diseases  which  have  heen  published  in  recent  years,  the  present 
one  promises  to  be  of  greatest  interest  and  value,  especially  from  the  standpoint  of  the 
general  practitioner  " — American  Medico-Surgical  Bulletin,  Feb.  22,  1896. 

"The  introduction  of  explanatory  wood-cuts  in  the  text  is  a  novel  and  most  important 
feature  which  greatly  furthers  the  easier  understanding  of  the  excellent  plates,  than  which 
nothing,  we  venture  to  say,  has  been  seen  better  in  point  of  correctness,  beauty,  and  general 
merit." — New  York  Medical  Journal ,  Feb.  15,  1896. 

"  An  interesting  feature  of  the  Atlas  is  the  descriptive  text,  which  is  written  for  each  picture 
bv  the  physician  who  treated  the  case  or  at  whose  instigation  the  models  have  been  made. 
We  predict  for  this  truly  beautiful  work  a  large  circulation  in  all  parts  of  the  medical  world 
where  the  names  St.  Louis  and  Baretta  have  preceded  it." — Medical  Record,  N.  Y.,  Feb.  i, 
1896. 

A  TEXT-BOOK  OF  MECHANO-THERAPY  (MASSAGE  AND 
MEDICAL  GYMNASTICS).  By  AXEL  V.  GRAFSTROM, -B.  Sc., 
M.  D.,  late  Lieutenant  in  the  Royal  Swedish  Army;  late  House  Physi- 
cian, City  Hospital,  Blackwell's  Island,  New  York.  I2mo,  139  pages, 
illustrated.  Cloth,  #1.00  net. 


CATALOGUE    OF  MEDICAL    WORKS.  2$ 

DISEASES  OF  THE  EYE.  A  Hand-Book  of  Ophthalmic  Prac- 
tice. By  G.  E.  DE  SCHWEINITZ,  M.  D.,  Professor  of  Ophthalmology  in 
the  Jefferson  Medical  College,  Philadelphia,  etc.  A  handsome  royal- 
octavo  volume  of  696  pages,  with  255  fine  illustrations,  many  of  which  are 
original,  and  2  chromo-lithographic  plates.  Prices :  Cloth,  $4.00  net ; 
Sheep  or  Half-Morocco,  $5.00  net. 

THIRD  EDITION,  THOROUGHLY  REVISED. 

In  the  third  edition  of  this  text-book,  destined,  it  is  hoped,  to  meet  the  favor- 
able reception  which  has  been  accorded  to  its  predecessors,  the  work  has  been 
revised  thoroughly,  and  much  new  matter  has  been  introduced.  Particular 
attention  has  been  given  to  the  important  relations  which  micro-organisms  bear 
to  many  ocular  diseases.  A  number  of  special  paragraphs  on  new  subjects  have 
been  introduced,  and  certain  articles,  including  a  portion  of  the  chapter  on 
Operations,  have  been  largely  rewritten,  or  at  least  materially  changed.  A 
number  of  new  illustrations  have  been  added.  The  Appendix  contains  a  full 
description  of  the  method  of  determining  the  corneal  astigmatism  with  the 
ophthalmometer  of  Javal  and  Schiotz,  and  the  rotation  of  the  eyes  with  the 
tropometer  of  Stevens. 

"A  work  that  will  meet  the  requirements  not  only  of  the  specialist,  but  of  the  general 
practitioner  in  a  rare  degree.  I  am  satisfied  that  unusual  success  awaits  it." 

WILLIAM  PEPPER,  M.  D. 

Provost  and  Professor  of  Theory  and  Practice  of  Medicine  and  Clinical  Medicine 
in  the  University  of  Pennsylvania. 

"A  clearly  written,  comprehensive  manual.  .  .  .  One  which  we  can  commend  to  students 
as  a  reliable  text-book,  written  with  an  evident  knowledge  of  the  wants  of  those  entering  upon 
the  study  of  this  special  branch  of  medical  science." — British  Medical  Journal. 

"  It  is  hardly  too  much  to  say  that  for  the  student  and  practitioner  beginning  the  study  of 
Ophthalmology,  tt  is  the  best  single  volume  at  present  published." — Medical  News. 

"  It  is  a  very  useful,  satisfactory,  and  safe  guide  for  the  student  and  the  practitioner,  and 
one  of  the  best  works  of  this  scope  in  the  English  language." — Annals  of  Ophthalmology. 

DISEASES  OF  WOMEN.  ByJ.  BLAND  SUTTON,  F.  R.  C.  S.,  Assistant 
Surgeon  to  Middlesex  Hospital,  and  Surgeon  to  Chelsea  Hospital,  London  ; 
and  ARTHUR  E.  GILES,  M.  D.,  B.  Sc.,  Lond.,  F.  R.C.  S.,  Edin.,  Assistant 
Surgeon  to  Chelsea  Hospital,  London.  436  pages,  handsomely  illustrated. 
Cloth,  $2.50  net. 

The  authors  have  placed  in  the  hands  of  the  physician  and  student  a  concise 
yet  comprehensive  guide  to  the  study  of  gynecology  in  its  most  modern  develop- 
ment. It  has  been  their  aim  to  relate  facts  nnd  describe  methods  belonging  to 
the  science  and  art  of  gynecology  in  a  way  that  will  prove  useful  to  students  for 
examination  purposes,  and  which  will  also  enable  the  general  physician  to  prac- 
tice this  important  department  of  surgery  with  advantage  to  his  patients  and  with 
satisfaction  to  himself. 

"  The  book  is  very  well  prepared,  and  is  certain  to  be  well  received  by  the  medical  public." 
— British  Medical  Journal. 

"The  text  has  been  carefully  prepared.  Nothing  essential  has  been  omitted,  and  its 
teachings  are  those  recommended  by  the  leading  authorities  of  the  &a.y."—Journal  of  the 
American  Medical  Association. 


26  W.   B.   SAUNDERS* 


TEXT-BOOK  UPON  THE  PATHOGENIC  BACTERIA.  Spe- 
cially written  for  Students  of  Medicine.  By  JOSEPH  McFARLAND, 
M.  D.,  Professor  of  Pathology  and  Bacteriology  in  the  Medico-Chirurgical 
College  of  Philadelphia,  etc.  497  pages,  finely  illustrated.  Price,  Cloth, 
$2. 50  net. 

SECOND  EDITION,  REVISED  AND  GREATLY  ENLARGED. 
The  work  is  intended  to  be  a  text-book  for  the  medical  student  and  for  the 
practitioner  who  has  had  no  recent  laboratory  training  in  this  department  of  medi- 
cal science.  The  instructions  given  as  to  needed  apparatus,  cultures,  stainings, 
microscopic  examinations,  etc.  are  ample  for  the  student's  needs,  and  will  afford 
to  the  physician  much  information  that  will  interest  and  profit  him  relative  to  a 
subject  which  modern  science  shows  to  go  far  in  explaining  the  etiology  of  many 
diseased  conditions. 

In  this  second  edition  the  work  has  been  brought  up  to  date  in  all  depart- 
ments of  the  subject,  and  numerous  additions  have  been  made  to  the  technique 
in  the  endeavor  to  make  the  book  fulfil  the  double  purpose  of  a  systematic  work 
upon  bacteria  and  a  laboratory  guide. 

"  It  is  excellently  adapted  for  the  medical  students  and  practitioners  for  whom  it  is  avowedly* 
written.  .  .  .  The  descriptions  given  are  accurate  and  readable,  and  the  book  should  prove 
useful  to  those  for  whom  it|is  written. — London  Lancet,  Aug.  29,  1896. 

"  The  author  has  succeeded  admirably  in  presenting  the  essential  details  of  bacteriological 
technics,  together  with  a  judiciously  chosen  summary  of  our  present  knowledge  of  pathogenic 
bacteria.  .  .  .  The  work,  we  think,  should  have  a  wide  circulation  among  English-speaking 
students  of  medicine." — N.  Y.  Medical  Journal,  April  4,  1896. 

"  The  book  will  be  found  of  considerable  use  by  medical  men  who  have  not  had  a  special 
bacteriological  training,  and  who  desire  to  understand  this  important  branch  of  medical 
science." — Edinburgh  Medical  journal,  July,  1896. 

LABORATORY    GUIDE    FOR    THE    BACTERIOLOGIST.      By 

LANGDON  FROTHINGHAM,  M.  D.  V.,  Assistant  in  Bacteriology  and  Veteri- 
nary Science,  Sheffield  Scientific  School,  Yale  University.  Illustrated. 
Price,  Cloth,  75  cents. 

The  technical  methods  involved  in  bacteria-culture,  methods  of  staining,  and 
microscopical  study  are  fully  described  and  arranged  as  simply  and  concisely  as 
possible.  The  book  is  especially  intended  for  use  in  laboratory  work 

"  It  is  a  convenient  and  useful  little  work,  and  will  more  than  repay  the  outlay  necessary 
for  its  purchase  in  the  saving  of  time  which  would  otherwise  be  consumed  in  looking  up  the 
various  points  of  technique  so  clearly  and  concisely  laid  down  in  its  pages." — American  Med.- 
Surg.  Bulletin. 

FEEDING  IN  EARLY  INFANCY.  By  ARTHUR  V.  MEIGS,  M.  D. 
Bound  in  limp  cloth,  flush  edges.  Price,  25  cents  net. 

SYNOPSIS  :  Analyses  of  Milk — Importance  of  the  Subject  of  Feeding  in  Early 
Infancy — Proportion  of  Casein  and  Sugar  in  Human  Milk — Time  to  Begin  Arti- 
ficial Feeding  of  Infants — Amount  of  Food  to  be  Administered  at  Each  Feed- 
ing— Intervals  between  Feedings — Increase  in  Amount  of  Food  at  Different 
Periods  of  Infant  Development — Unsuitableness  of  Condensed  Milk  as  a  Sub- 
stitute for  Mother's  Milk — Objections  to  Sterilization  or  "  Pasteurization  "  of 
Milk — Advances  made  in  the  Method  of  Artificial  Feeding  of  Infants. 


CATALOGUE    OF  MEDICAL    WORKS.  2 7 

MATERIA  MEDICA  FOR  NURSES.  By  EMILY  A.  M.  STONEY, 
Graduate  of  the  Training-school  for  Nurses,  Lawrence,  Mass, ;  late 
Superintendent  of  the  Training-school  for  Nurses,  Carney  Hospital,  South 
Boston,  Mass.  Handsome  octavo,  300  pages.  Cloth,  $1.50  net. 

The  present  book  differs  from  other  similar  works  in  several  features,  all  of 
which  are  introduced  to  render  it  more  practical  and  generally  useful.  The 
general  plan  of  contents  follows  the  lines  laid  down  in  training-schools  for 
nurses,  but  the  book  contains  much  useful  matter  not  usually  included  in  works 
of  this  character,  such  as  Poison-emergencies,  Ready  Dose-list,  Weights  and 
Measures,  etc.,  as  well  as  a  Glossary,  defining  all  the  terms  in  Materia  Medica, 
and  describing  all  the  latest  drugs  and  remedies,  which  have  been  generally 
neglected  by  other  books  of  the  kind. 

ESSENTIALS  OF  ANATOMY  AND  MANUAL  OF  PRACTI- 
CAL DISSECTION,  containing  "  Hints  on  Dissection."  By  CHARLES 
B.  NANCREDE,  M.  D.,  Professor  of  Surgery  and  Clinical  Surgery  in  the 
University  of  Michigan,  Ann  Arbor;  Corresponding  Member  of  the  Royal 
Academy  of  Medicine,  Rome,  Italy ;  late  Surgeon  Jefferson  Medical  Col- 
lege, etc.  Fourth  and  revised  edition.  lost  8vo,  over  500  pages,  with 
handsome  full-page  lithographic  plates  in  colors,  and  over  200  illustrations. 
Price  :  Extra  Cloth  or  Oilcloth  for  the  dissection-room,  $2.00  net. 

Neither  pains  nor  expense  has  been  spared  to  make  this  work  the  most  ex- 
haustive yet  concise  Student's  Manual  of  Anatomy  and  ^Dissection  ever  pub- 
lished, either  in  America  or  in  Europe. 

The  colored  plates  are  designed  to  aid  the  student  in  dissecting  the  muscles, 
arteries,  veins,  and  nerves.  The  wood-cuts  have  all  been  specially  drawn  and 
engraved,  and  an  Appendix  added  containing  60  illustrations  representing  the 
structure  of  the  entire  human  skeleton,  the  whole  being  based  on  the  eleventh 
edition  of  Gray's  Anatomy, 

A  MANUAL  OF  PRACTICE  OF  MEDICINE.  By  A.  A.  STEVENS, 
A.  M.,  M.  D.,  Instructor  in  Physical  Diagnosis  in  the  University  of  Penn- 
sylvania, and  Professor  of  Pathology  in  the  Woman's  Medical  College  of 
Pennsylvania.  Specially  intended  for  students  preparing  for  graduation 
and  hospital  examinations.  Post  8vo,  519  pages.  Numerous  illustrations 
and  selected  formulae.  Price,  bound  in  flexible  leather,  $2.00  net. 

FIFTH  EDITION,  REVISED  AND  ENLARGED. 

Contributions  to  the  science  of  medicine  have  poured  in  so  rapidly  during  the 
2ast  quarter  of  a  century  that  it  is  well-nigh  impossible  for  the  student,  with  the 
limited  time  at  his  disposal,  to  master  elaborate  treatises  or  to  cull  from  them 
that  knowledge  which  is  absolutely  essential.  From  an  extended  experience  in 
teaching,  the  author  has  been  enabled,  by  classification,  to  group  allied  symp- 
toms, and  by  the  judicious  elimination  of  theories  and  redundant  explanations 
to  bring  within  a  comparatively  small  compass  a  complete  outline  of  the  prac- 
tice of  medicine. 


28  W.   B.   SAUNDERS 


MANUAL  OF  MATERIA  MEDICA  AND  THERAPEUTICS. 

By  A.  A.  STEVENS,  A.  M.,  M.  D.,  Instructor  of  Physical  Diagnosis  in  the 
University  of  Pennsylvania,  and  Professor  of  Pathology  in  the  Woman's 
Medical  College  of  Pennsylvania.  445  pages.  Price,  bound  in  flexible 
leather,  $2.25. 

SECOND  EDITION,   REVISED. 

This  wholly  new  volume,  which  is  based  on  the  last  edition  of  the  Pharma- 
copceia,  comprehends  the  following  sections :  Physiological  Action  of  Drugs ; 
Drugs;  Remedial  Measures  other  than  Drugs;  Applied  Therapeutics;  Incom- 
patibility in  Prescriptions;  Table  of  Doses;  Index  of  Drugs;  and  Index  of 
Diseases ;  the  treatment  being  elucidated  by  more  than  two  hundred  formulae. 

"  The  author  is  to  be  congratulated  upon  having  presented  the  medical  student  with  as 
accurate  a  manual  of  therapeutics  as  it  is  possible  to  prepare." —  Therapeutic  Gazette. 

"  Far  superior  to  most  of  its  class ;  in  fact,  it  is  very  good.  Moreover,  the  book  is  reliable 
and  accurate." — New  York  Medical  Journal. 

"  The  author  has  faithfully  presented  modern  therapeutics  in  a  comprehensive  work,  .  .  . 
and  it  will  be  found  a  reliable  guide."—  University  Medical  Magazine. 

NOTES  ON  THE  NEWER  REMEDIES:  their  Therapeutic  Ap- 
plications and  Modes  of  Administration.  By  DAVID  CERNA,  M.  D., 
PH.  D.,  Demonstrator  of  and  Lecturer  on  Experimental  Therapeutics  in 
the  University  of  Pennsylvania.  Post-octavo,  253  pages.  Price,  $1.25. 

SECOND  EDITION,  RE-WRITTEN  AND  GREATLY   ENLARGED. 

The  work  takes  up  in  alphabetical  order  all  the  newer  remedies,  giving  their 
physical  properties,  solubility,  therapeutic  applications,  administration,  and 
chemical  formula. 

It  thus  forms  a  very  valuable  addition  to  the  various  works  on  therapeutics 
now  in  existence. 

Chemists  are  so  multiplying  compounds,  that,  if  each  compound  is  to  be  thor- 
oughly studied,  investigations  must  be  carried  far  enough  to  determine  the  prac- 
tical importance  of  the  new  agents. 

"  Especially  valuable  because  of  its  completeness,  its  accuracy,  its  systematic  consider- 
ation of  the  properties  and  therapy  of  many  remedies  of  which  doctors  generally  know  but 
little,  expressed  in  a  brief  yet  terse  manner." — Chicago  Clinical  Review. 


TEMPERATURE  CHART.     Prepared  by  D.  T.  LAINE,  M.  D.      Size 
8x  13^  inches.     Price,  per  pad  of  25  charts,  50  cents. 

A  conveniently  arranged  chart  for  recording  Temperature,  with  columns  for 
daily  amounts  of  Urinary  and  Fecal  Excretions,  Food,  Remarks,  etc.  On  the 
back  of  each  chart  is  given  in  full  the  method  of  Brand  in  the  treatment  of 
Typhoid  Fever. 


CATALOGUE    OF  MEDICAL    WORKS.  29 


A  TEXT-BOOK  OF  HISTOLOGY,  DESCRIPTIVE  AND  PRAC- 
TICAL. For  the  Use  of  Students.  By  ARTHUR  CLARKSON,  M.  B., 
C.  M.,  Edin.,  formerly  Demonstrator  of  Physiology  in  the  Owen's  College, 
Manchester;  late  Demonstrator  of  Physiology  in  the  Yorkshire  College, 
Leeds.  Large  8vo,  554  pages,  with  22  engravings  in  the  text,  and  174 
beautifully  colored  original  illustrations.  Price,  strongly  bound  in  Cloth, 
$4.00  net. 

The  purpose  of  the  writer  in  this  work  has  been  to  furnish  the  student  of  His- 
tology, in  one  volume,  with  both  the  descriptive  and  the  practical  part  of  the 
science.  The  first  two  chapters  are  devoted  to  the  consideration  of  the  general 
meihods  of  Histology ;  subsequently,  in  each  chapter,  the  structure  of  the  tissue 
or  organ  is  first  systematically  described,  the  student  is  then  taken  tutorially  over 
the  specimens  illustrating  it,  and,  finally,  an  appendix  affords  a  short  note  of  the 
methods  of  preparation; 

"The  work  must  be  considered  a  valuable  addition  to  the  list  of  available  text-books,  and 
is  to  be  highly  recommended." — ffew  York  Medical  Journal. 

"One  of  the  best  works  for  students  we  have  ever  noticed.  We  predict  that  the  book  will 
attain  a  well-deserved  popularity  among  our  students." — Chicago  Medical  Recorder. 

THE  PATHOLOGY  AND  TREATMENT  OF  SEXUAL  IM- 
POTENCE. By  VICTOR  G.  VECKI,  M.  D.  From  the  second  Ger- 
man edition,  revised  and  rewritten.  Demi-octavo,  about  300  pages. 
Cloth,  $2.00  net. 

The  subject  of  impotence  has  but  seldom  been  treated  in  this  country  in  the 
truly  scientific  spirit  that  it  deserves,  and  this  volume  will  come  to  many  as  a 
revelation  of  the  possibilities  of  therapeusis  in  this  important  field.  Dr.  Vecki's 
work  has  long  been  favorably  known,  and  the  German  book  has  received  the 
highest  consideration.  This  edition  is  more  than  a  mere  translation,  for,  although 
based  on  the  German  edition,  it  has  been  entirely  rewritten  by  the  author  in 
English. 

"  The  work  can  be  recommended  as  a  scholarly  treatise  on  its  subject,  and  it  can  be  read 
with  advantage  by  many  practitioners."— Journal  of  the  American  Medical  Association. 

DISEASES  OF  THE  NOSE  AND  THROAT.  By  D.  BRADEN  KYLE, 
M.  D.,  Clinical  Professor  of  Laryngology  and  Rhinology,  Jefferson  Medi- 
cal College,  Philadelphia;  Consulting  Laryngologist,  Rhinologist,  and 
Otologist,  St.  Agnes'  Hospital.  Octavo  volume  of  646  pnges,  with  over 
150  illustrations  and  6  lithographic  plates.  Cloth,  $4.00  net ;  Half  Mo- 
rocco, $5.00  net. 

This  book  presents  the  subject  of  Diseases  of  the  Nose  and  Throat  in  as  con- 
cise a  manner  as  is  consistent  with  clearness,  keeping  in  mind  the  needs  of  the 
student  and  general  practitioner  as  well  as  those  of  the  specialist.  The  arrange- 
ment and  classification  are  based  on  modern  pathology,  and  the  pathological 
views  advanced  are  supported  by  drawings  of  microscopical  sections  made  in 
the  author's  own  laboratory. 


30  W.   B.   SA  UNDER? 


DISEASES  OF  WOMEN.  By  HENRY  J.  GARRIGUES,  A.M.,  M.  D., 
Professor  of  Gynecology  in  the  New  York  School  of  Clinical  Medicine; 
Gynecologist  to  St.  Mark's  Hospital  and  to  the  German  Dispensary,  New 
York  City.  In  one  handsome  octavo  volume  of  728  pages,  illustrated  by 
335  engravings  and  colored  plates.  Prices:  Cloth,  #4.00  net;  Sheep  or 
Half-Morocco,  $5.00  net. 

A  PRACTICAL  work  on  gynecology  for  the  use  of  students  and  practitioners, 
written  in  a  terse  and  concise  manner.  The  importance  of  a  thorough  know- 
ledge of  the  anatomy  of  the  female  pelvic  organs  has  been  fully  recognized  by 
the  author,  and  considerable  space  has  been  devoted  to  the  subject.  The  chap- 
ters on  Operations  and  on  Treatment  are  thoroughly  modern,  and  are  based 
upon  the  large  hospital  and  private  practice  of  the  author.  The  text  is  eluci- 
dated by  a  large  number  of  illustrations  and  colored  plates,  many  of  them  being 
original,  and  forming  a  complete  atlas  for  studying  embryology  and  the  anatomy 
of  the  female  genitalia,  besides  exemplifying,  whenever  needed,  morbid  condi- 
tions, instruments,  apparatus,  and  operations. 

Second  Edition,  Thoroughly  Revised. 

The  first  edition  of  this  work  rnet  with  a  most  appreciative  reception  by  the 
medical  press  and  profession  both  in  this  country  and  abroad,  and  was  adopted 
as  a  text-book  or  recommended  as  a  book  of  reference  by  nearly  one  hundred 
colleges  in  the  United  States  and  Canada.  The  author  has  availed  himself  of 
the  opportunity  afforded  by  this  revision  to  embody  the  latest  approved  advances 
in  the  treatment  employed  in  this  important  branch  of  Medicine.  He  has  also 
more  extensively  expressed  his  own  opinion  on  the  comparative  value  of  the 
different  methods  of  treatment  employed. 

"  One  of  the  best  text-books  for  students  and  practitioners  which  has  been  published  in 
the  English  language;  it  is  condensed,  clear,  and  comprehensive.  The  profound  learning 
and  great  clinical  experience  of  the  distinguished  author  find  expression  in  this  book  in  a 
most  attractive  and  instructive  form.  Young  practitioners,  to  whom  experienced  consultants 
may  not  be  available,  will  find  in  this  book  invaluable  counsel  and  help." 

THAD.  A.  RBAMY,  M.  D.,  LL.D., 

Profettor  ef  Clinical  Gynecology,  Medical  College  of  Ohio ;  Gynecologist  to  the  Good 
Samaritan  and  Cincinnati  Hospitals. 


\  SYLLABUS  OF  GYNECOLOGY,  arranged  in  conformity  witn 
"An  American  Text-Book  of  Gynecology."  By  J.  W.  LONG,  M.  D., 
Professor  of  Diseases  of  Women  and  Children,  Medical  College  of  Vir- 
ginia, etc.  Price,  Cloth  (interleaved),  $1.00  net. 

Based  upon  the  teaching  and  methods  laid  down  in  the  larger  work;  this  will 
not  only  be  useful  as  a  supplementary  volume,  but  to  those  who  do  not  already 
possess  the  text-book  it  will  also  have  an  independent  value  as  an  aid  to  the 
practitioner  in  gynecological  work,  and  to  the  student  as  a  guide  in  the  lecture- 
room,  as  the  subject  is  presented  in  a  manner  at  once  systematic,  clear,  succinct, 
rod  practical. 


CATALOGUE    OF  MEDICAL    WORKS.  31 

THE  AMERICAN  POCKET  MEDICAL  DICTIONARY.  Edited 
by  W.  A.  NEWMAN  BORLAND,  M.  D.,  Assistant  Obstetrician  to  the  Hospital 
of  the  University  of  Pennsylvania ;  Fellow  of  the  American  Academy  of 
Medicine.  Containing  the  pronunciation  and  definition  of  all  the  principal 
words  used  in  medicine  and  the  kindred  sciences,  with  64  extensive  tables. 
Handsomely  bound  in  flexible  leather,  limp,  with  gold  edges  and  patent 
thumb  index.  Price,  $l.oo  net ;  with  thumb  index,  $1.25  net. 

SECOND  EDITION,  REVISED. 

This  is  the  ideal  pocket  lexicon.  It  is  an  absolutely  new  book,  and  not  a  re- 
vision of  any  old  work.  It  is  complete,  defining  all  the  terms  of  modern  medi- 
cine and  forming  an  unusually  complete  vocabulary.  It  gives  the  pronunciation 
of  all  the  terms.  It  makes  a  special  feature  of  the  newer  words  neglected  by 
other  dictionaries.  It  contains  a  wealth  of  anatomical  tables  of  special  value  to 
students.  It  forms  a  handy  volume,  indispensable  to  every  medical  man. 

SAUNDERS'  POCKET  MEDICAL  FORMULARY.  By  WILLIAM 
M.  POWELL,  M.  D.,  Attending  Physician  to  the  Mercer  House  for  Invalid 
Women  at  Atlantic  City.  Containing  1800  Formulae,  selected  from  several 
hundred  of  the  best-known  authorities.  Forming  a  handsome  and  con- 
venient pocket  companion  of  nearly  300  printed  pages,  with  blank  leaves 
for  Additions ;  with  an  Appendix  containing  Posological  Table,  Formulae 
and  Doses  for  Hypodermatic  Medication,  Poisons  and  their  Antidotes, 
Diameters  of  the  Female  Pelvis  and  Foetal  Head,  Obstetrical  Table,  Diet 
List  for  Various  Diseases,  Materials  and  Drugs  used  in  Antiseptic  Surgery, 
Treatment  of  Asphyxia  from  Drowning,  Surgical  Remembrancer,  Tables 
of  Incompatibles,  Eruptive  Fevers,  Weights  and  Measures,  etc.  Hand- 
somely bound  in  morocco,  with  side  index,  wallet,  and  flap.  Price,  $1-75 
net. 

FIFTH  EDITION,  THOROUGHLY  REVISED. 

"This  little  book,  that  can  be  conveniently  carried  in  the  pocket,  contains  an  immense 
amount  of  material.  It  is  very  useful,  and  as  the  name  of  the  author  of  each  prescription  is 
given, is  unusually  reliable." — Neiv  York  Medical  Record. 

A  COMPENDIUM  OF  INSANITY.  By  JOHN  B.  CHAPIN,  M.D.,  LL.D., 
Physician-in-Chief,  Pennsylvania  Hospital  for  the  Insane;  late  Physician- 
Superintendent  ofthe  Willard  State  Hospital,  New  York ;  Honorary  Mem- 
ber of  the  Medico- Psychological  Society  of  Great  Britain,  of  the  Society  of 
Mental  Medicine  of  Belgium.  I2mo,  234  pages,  illust.  Cloth,  $1.25  net. 

The  author  has  given,  in  a  condensed  and  concise  form,  a  compendium  of 
Diseases  of  the  Mind,  for  the  convenient  use  and  aid  of  physicians  and  students. 
It  contains  a  clear,  concise  statement  of  the  clinical  aspects  of  the  various  ab- 
normal mental  conditions,  with  directions  as  to  the  most  approved  methods  of 
managing  and  treating  the  insane. 

"  The  practical  parts  of  Dr.  Chapin's  book  are  what  constitute  its  distinctive  merit.  We 
desire  especially,  however,  to  call  attention  to  the  fact  that  in  the  subject  of  the  therapeutics 
of  insanity  the  work  is  exceedingly  valuable.  The  author  has  made  a  distinct  addition  to  the 
literature  of  his  specialty." — PJiiladelfkia  Medical  Journal. 


32  W.   B.    SAUNDERS* 


AN  OPERATION  BLANK,  with  Lists  of  Instruments,  etc.  re- 
quired in  Various  Operations.  Prepared  by  W.  W.  KEEN,  M.  D., 
LL.D.,  Professor  of  Principles  of  Surgery  in  the  Jefferson  Medical  Col- 
lege, Philadelphia.  Price  per  Pad,  containing  Blanks  for  fifty  operations, 
50  cents  net. 

SECOND  EDITION,  REVISED  FORM. 

A  convenient  blank,  suitable  for  all  operations,  giving  complete  instructions 
regarding  necessary  preparation  of  patient,  etc.,  with  a  full  list  of  dressings  and 
medicines  to  be  employed. 

On  the  back  of  each  blank  is  a  list  of  instruments  used— viz.  general  instru 
ments,  etc.,  required  for  all  operations ;  and  special  instruments  for  surgery  of 
the  brain  and  spine,  mouth  and  throat,  abdomen,  rectum,  male  and  female 
genito-urinary  organs,  the  bones,  etc. 

The  whole  forming  a  neat  pad,  arranged  for  hanging  on  the  wall  of  a  sur- 
geon's office  or  in  the  hospital  operating-room. 

"  Will  serve  a  useful  purpose  for  the  surgeon  in  reminding  him  of  the  details  of  prepa- 
ration for  the  patient  and  the  room  as  well  as  for  the  instruments,  dressings,  and  antiseptics 
needed  " — New  York  Medical  Record 

"  Covers  about  all  that  can  be  needed  in  any  operation." — American  Lancet. 
"  The  plan  is  a  capital  one."— Boston  Medical  and  Surgical  Journal. 

LABORATORY  EXERCISES  IN  BOTANY.  By  EDSON  S.  BASTIN, 
M.  A.,  Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  Col- 
lege of  Pharmacy.  Octavo  volume  of  536  pages,  87  full-page  plates.  Price, 
Cloth,  $2.50. 

This  work  is  intended  for  the  beginner  and  the  advanced  student,  and  it  fully 
covers  the  structure  of  flowering  plants,  roots,  ordinary  stems,  rhizomes,  tubers, 
bulbs,  leaves,  flowers,  fruits,  and  seeds.  Particular  attention  is  given  to  the  gross 
and  microscopical  structure  of  plants,  and  to  those  used  in  medicine.  Illustra- 
tions have  freely  been  used  to  elucidate  the  text,  and  a  complete  index  to  facil- 
itate reference  has  been  added. 

"  There  is  no  work  like  it  in  the  pharmaceutical  or  botanical  literature  of  this  country,  and 
we  predict  for  it  a  wide  circulation." — American  Journal  of  Pharmacy. 

DIET  IN  SICKNESS  AND  IN  HEALTH.  By  MRS.  ERNEST  HART, 
formerly  Student  of  the  Faculty  of  Medicine  of  Paris  and  of  the  London 
School  of  Medicine  for  Women ;  with  an  INTRODUCTION  by  Sir  Henry 
Thompson,  F.  R.  C.  S.,  M.  D.,  London.  220  pages ;  illustrated.  Price, 
Cloth,  #1.50. 

Useful  to  those  who  have  to  nurse,  feed,  and  prescribe  for  the  sick.  In 
each  case  the  accepted  causation  of  the  disease  and  the  reasons  for  the  special 
diet  prescribed  are  briefly  described.  Medical  men  will  find  the  dietaries  and 
recipes  practically  useful,  and  likely  to  save  them  trouble  in  directing  the  dietetic 
treatment  of  patients. 


CATALOGUE    OF  MEDICAL    WORKS.  33 

A  MANUAL   OF    PHYSIOLOGY,  with    Practical    Exercises.     For 

Students  and  Practitioners.  By  G.  N.  STEWART,  M.  A.,  M.  D.,  D.  Sc., 
lately  Examiner  in  Physiology,  University  of  Aberdeen,  and  of  the  New 
Museums,  Cambridge  University ;  Professor  of  Physiology  in  the  Western 
Reserve  University,  Cleveland,  Ohio.  Handsome  octavo  volume  of  848 
pages,  with  300  illustrations  in  the  text,  and  5  colored  plates.  Price,  Cloth, 
£3.75  net. 

THIRD  EDITION,  REVISED. 

"  It  will  make  its  way  by  sheer  force  of  merit,  and  amply  deserves  to  do  so.     It  is  one  oj 
the  very  best  English  text-books  on  the  subject. ' ' — London  Lancet. 

"  Of  the  many  text-books  of  physiology  published,  we  do  not  know  of  one  that  so  nearly 
comes  up  to  the  ideal  as  does  Professor  Stewart's  volume." — British  Medical  Journal. 

ESSENTIALS  OF  PHYSICAL  DIAGNOSIS  OF  THE  THORAX. 

By  ARTHUR  M.  CORWIN,  A.  M.,  M.  D.,  Demonstrator  of  Physical  Diagno- 
sis in  the  Rush  Medical  College,  Chicago ;  Attending  Physician  to  the 
Central  Free  Dispensary,  Department  of  Rhinology,  Laryngology,  and 
Diseases  of  the  Chest.  219  pages.  Illustrated.  Cloth,  flexible  covers. 
Price,  $1.25  net. 

THIRD  EDITION,  THOROUGHLY  REVISED  AND  ENLARGED. 
SYLLABUS  OF  OBSTETRICAL  LECTURES  in  the  Medical 
Department,  University  of  Pennsylvania.  By  RICHARD  C.  NORRIS, 
A.  M.,  M.  D.,  Lecturer  on  Clinical  and  Operative  Obstetrics,  University 
of  Pennsylvania.  Third  edition,  thoroughly  revised  and  enlarged.  Crown 
8vo.  Price,  Cloth,  interleaved  for  notes,  $2.00  net. 

"  This  work  is  so  far  superior  to  others  on  the  same  subject  that  we  take  pleasure  in  call- 
ing attention  briefly  to  its  excellent  features.  It  covers  the  subject  thoroughly,  and.  will 
prove  invaluable  both  to  the  student  and  the  practitioner.  The  author  has  introduced  a 
number  of  valuable  hints  which  would  only  occur  to  one  who  was  himself  an  experienced 
teacher  of  obstetrics.  The  subject-matter  is  clear,  forcible,  and  modern.  We  are  especially 
pleased  with  the  portion  devoted  to  the  practical  duties  of  the  accoucheur,  care  of  the  child, 
etc.  The  paragraphs  on  antiseptics  are  admirable;  there  is  no  doubtful  tone  in  the  direc- 
tions given.  No  details  are  regarded  as  unimportant ;  no  minor  matters  omitted.  We  ven- 
ture to  say  that  even  the  old  practitioner  will  find  useful  hints  in  this  direction  which  he  can- 
not afford  to  despise." — New  York  Medical  Record. 

A  SYLLABUS  OF  LECTURES  ON  THE  PRACTICE  OF  SUR- 
GERY, arranged  in  conformity  with  "  An  American  Text-Book 
of  Surgery."  By  N.  SENN,  M.  D.,  PH.  D.,  Professor  of  Surgery  in  Rush 
Medical  College,  Chicago,  and  in  the  Chicago  Polyclinic.  Price,  $2.00. 

This  work  by  so  eminent  an  author,  himself  one  of  the  contributors  to 
"  An  American  Text-Book  of  Surgery,"  will  prove  of  exceptional  value  to 
the  advanced  student  who  has  adopted  that  work  as  his  text-book.  It  is  not 
only  the  syllabus  of  an  unrivalled  course  of  surgical  practice,  but  it  is  also  an 
epitome  of  or  supplement  to  the  larger  work. 

"  The  author  has  evidently  spared  no  pains  in  making  his  Syllabus  thoroughly  comprehen- 
sive, and  has  added  new  matter  and  alluded  to  the  most  recent  authors  and  operations.  Full 
references  are  also  given  to  all  requisite  details  of  surgical  anatomy  and  pathology." — British 
Medical  Journal ',  London. 


34  W.    B.   SAUNDERS' 


THE  CARE  OF  THE  BABY.  By  J.  P.  CROZER  GRIFFITH,  M.  D., 
Clinical  Professor  of  Diseases  of  Children,  University  of  Pennsylvania; 
Physician  to  the  Children's  Hospital,  Philadelphia,  etc.  404  pages,  with 
67  illustrations  in  the  text,  and  5  plates.  lamo.  Price,  $1.50. 

SECOND  EDITION,  REVISED. 

A  reliable  guide  not  only  for  mothers,  but  also  for  medical  students  and 
practitioners  whose  opportunities  for  observing  children  have  been  limited. 

"The  whole  book  is  characterized  by  rare  good  sense,  and  is  evidently  written  by  a  mas- 
ter hand.  It  can  be  read  with  benefit  not  only  by  mothers,  but  by  medical  students  and  by 
any  practitioners  who  have  not  had  large  opportunities  for  observing  children."— American 
Journal  of  Obstetrics. 

THE  NURSE'S  DICTIONARY  of  Medical  Terms  and  Nursing 
Treatment,  containing  Definitions  of  the  Principal  Medical  and  Nursing 
Terms,  Abbreviations,  and  Physiological  Names,  and  Descriptions  oi'  the 
Instruments,  Drugs,  Diseases,  Accidents,  Treatments,  Operations,  Foods, 
Appliances,  etc.  encountered  in  the  ward  or  the  sick-room.  By  HONNOR 
MORTEN,  author  of  "How  to  Become  a  Nurse,"  "Sketches  of  Hospital 
Life,"  etc.  l6ino,  140  pages.  Price,  Cloth,  $1.00. 

This  little  volume  is  intended  for  use  merely  as  a  small  reference-book  which 
can  be  consulted  at  the  bedside  or  in  the  ward.  It  gives  sufficient  explanation 
to  the  nurse  to  enable  her  to  comprehend  a  case  until  she  has  leisure  to  look  up 
larger  and  fuller  works  on  the  subject 

DIET  LISTS  AND  SICK-ROOM  DIETARY.  By  JEROME  B.  THOMAS, 
M.  D.,  Visiting  Physician  to  the  Home  for  Friendless  Women  and  Children 
and  to  the  Newsboys'  Home ;  Assistant  Visiting  Physician  to  the  Kings 
County  Hospital;  Assistant  Bacteriologist,  Brooklyn  Health  Department. 
Price,  Cloth,  $1.50  (Send  for  specimen  List.) 

One  hundred  and  sixty  detachable  (perforated)  diet  lists  for  Albuminuria, 
Anaemia  and  Debility,  Constipation,  Diabetes,  Diarrhoea,  Dyspepsia,  Fevers, 
Gout  or  Uric- Acid  Diathesis,  Obesity,  and  Tuberculosis.  Also  forty  detachable 
sheets  of  Sick-Room  Dietary,  containing  full  instructions  for  preparation  of 
easily-digested  foods  necessary  for  invalids.  Each  list  is  numbered  only,  the 
disease  for  which  it  is  to  be  used  in  no  case  being  mentioned,  an  index  key 
being  reserved  for  the  physician's  private  use. 

DIETS  FOR  INFANTS  AND  CHILDREN  IN  HEALTH  AND 
IN  DISEASE.  By  Louis  STARR,  M.  D.,  Editor  of  "  An  American 
Text-Book  of  the  Diseases  of  Children."  230  blanks  (pocket-book  size) 
perforated  and  neatly  bound  in  flexible  morocco.  Price,  $1.25  net. 

The  first  series  of  blanks  are  prepared  for  the  first  seven  months  of  infant 
life;  each  blank  indicates  the  ingredients,  but  not  the  quantities,  of  the  food, 
the  latter  directions  being  left  for  the  physician.  After  the  seventh  month, 
modifications  being  less  necessary,  the  diet  lists  are  printed  in  full.  Formula 
fo:  (fie  preparation  of  diluents  and  foods  are  appended. 


CATALOGUE   OF  MEDICAL    WORKS.  35 

HOW  TO  EXAMINE  FOR  LIFE  INSURANCE.  By  JOHN  M. 
KEATING,  M.  D.,  Fellow  of  the  College  of  Physicians  and  Surgeons  of 
Philadelphia;  Vice-President  of  the  American  Paediatric  Society;  Ex- 
President  of  the  Association  of  Life  Insurance  Medical  Directors.  Royal 
8vo,  211  pages,  with  two  large  half-tone  illustrations,  and  a  plate  prepared 
.  by  Dr.  McClellan  from  special  dissections;  also,  numerous  cuts  to  elucidate 
the  text.  Third  edition.  Price,  Cloth,  $2.00  net. 

"  This  is  by  far  the  most  useful  book  which  has  yet  appeared  on  insurance  examination,  a 
subject  of  growing  interest  and  importance.  Not  the  least  valuable  portion  of  the  volume  is 
Part  II.,  which  consists  of  instructions  issued  to  their  examining  physicians  by  twenty-four 
representative  companies  of  this  country.  As  the  proofs  of  these  instructions  were  corrected 
by  the  directors  of  the  companies,  they  form  the  latest  instructions  obtainable.  If  for  these 
alone,  the  book  should  be  at  the  right  hand  of  every  physician  interested  in  this  special  branch 
of  medical  science." — The  Medical  News,  Philadelphia. 

NURSING:  ITS  PRINCIPLES  AND  PRACTICE.  By  ISABEL 
ADAMS  HAMPTON,  Graduate  of  the  New  York  Training  School  for 
Nurses  attached  to  Bellevue  Hospital ;  Superintendent  of  Nurses  and 
Principal  of  the  Training  School  for  Nurses,  Johns  Hopkins  Hospital, 
Baltimore,  Md. ;  late  Superintendent  of  Nurses,  Illinois  Training  School 
for  Nurses,  Chicago,  111.  In  one  very  handsome  I2mo  volume  of  512 
pages,  illustrated.  Price,  Cloth,  $2.00  net. 

SECOND   EDITION,  REVISED  AND  ENLARGED. 

This  original  work  on  the  important  subject  of  nursing  is  at  once  comprehensive 
and  systematic.  It  is  written  in  a  clear,  accurate,  and  readable  style,  suitable 
alike  to  the  student  and  the  lay  reader.  Such  a  work  has  long  been  a  desidera- 
tum with  those  entrusted  with  the  management  of  hospitals  and  the  instruction  of 
nurses  in  training-schools.  It  is  also  of  especial  value  to  the  graduated  nurse 
who  desires  to  acquire  a  practical  working  knowledge  of  the  care  of  the  sick 
and  the  hygiene  of  the  sick-room. 

OBSTETRIC  ACCIDENTS,  EMERGENCIES,  AND  OPERA- 
TIONS. By  L.  CH.  BOISUNIERE,  M.  D.,  late  Emeritus  Professor  of 
Obstetrics  in  the  St.  Louis  Medical  College.  381  pages,  handsomely  illus- 
trated. Price,  $2.00  net. 

"  For  the  use  of  the  practitioner  who,  when  away  from  home,  has  not  the 
opportunity  of  consulting  a  library  or  of  calling  a  friend  in  consultation.  He 
then,  being  thrown  upon  his  own  resources,  will  find  this  book  of  benefit  in 
guiding  and  assisting  him  in  emergencies." 

INFANT'S  WEIGHT  CHART.  Designed  by  J.  P.  CROZF.R  GRIFFITH, 
M.  D.,  Clinical  Professor  of  Diseases  of  Children  in  the  University  of  Penn 
sylvania.  25  charts  in  each  pad.  Price  per  pad,  50  cents  net. 

A  convenient  blank  for  keeping  a  record  of  the  child's  weight  during  the  first 
two  yenrs  of  life.  Printed  on  each  chart  is  a  curve  representing  the  average  weight 
of  a  healthy  infant,  so  that  any  deviation  from  the  normal  can  readily  be  detected. 


SAUNDERS' 
NEW  SERIES 
OF  MANUALS 


for  Students 
and 
Practitioners. 


THAT  there  exists  a.  need  for  thoroughly  reliable  hand-books  on  the  leading 
branches  of  Medicine  and  Surgery  is  a  fact  amply  demonstrated  by  the 
favor  with  which  the  SAUNDERS  NEW  SERIES  OF  MANUALS  have  been 
received  by  medical  students  and  practitioners  and  by  the  Medical  Press. 
These  manuals  are  not  merely  condensations  from  present  literature,  but 
are  ably  written  by  well-known  authors  and  practitioners,  most  of  them  being 
teachers  in  representative  American  colleges.  Each  volume  is  concisely  and 
authoritatively  written  and  exhaustive  in  detail,  without  being  encumbered 
with  the  introduction  of  "cases,"  which  so  largely  expand  the  ordinary  text- 
book. These  manuals  will  therefore  form  an  admirable  collection  of  advanced 
lectures,  useful  alike  to  the  medical  student  and  the  practitioner:  to  the  latter, 
too  busy  to  search  through  page  after  page  of  elaborate  treatises  for  what  he 
wants  to  know,  they  will  prove  of  inestimable  value  ;  to  the  former  they  will 
afford  safe  guides  to  the  essential  points  of  study. 

The  SAUNDERS  NEW  SERIES  OF  MANUALS  are  conceded  to  be 
superior  to  any  similar  books  now  on  the  market.  No  other  manuals  afford  so 
much  information  in  such  a  concise  and  available  form.  A  liberal  expenditure 
has  enabled  the  publisher  to  render  the  mechanical  portion  of  the  work  worthy 
of  the  high  literary  standard  attained  by  these  books. 

Any  of  these  Manuals  will  be  mailed  on  receipt  of  price  (see  next  page 
for  List). 


SAUNDERS'  NEW  SERIES  OF  MANUALS, 


VOLUMES  PUBLISHED. 


PHYSIOLOGY.  By  JOSEPH  HOWARD  RAYMOND,  A.  M  ,  M.  p.,  Professor 
of  Physiology  and  Hygiene  and  Lecturer  on  Gynecology  in  the  Long 
Island  College  Hospital,  etc.  Price,  $1.25  net. 

SURGERY,  General  and  Operative.  By  JOHN  CHALMERS  DACosTA, 
M.  I).,  Professor  of  Clinical  Singer),  Jefferson  Medical  College,  Philadel- 
phia. Second  edition,  revised  and  greatly  enlarged.  Octavo,  911  pages, 
386  illustrations.  Cloth,  $4.00  net ;  Half-Morocco,  $5.00  net. 

DOSE-BOOK  AND  MANUAL  OF  PRESCRIPTION- WRITING. 

By  E.  Q.  THORNTON,   M.  D.,  Demonstrator  of  Therapeutics,  Jefferson 
Medical  College,  Philadelphia.     Price,  $1.25  net. 

MEDICAL  JURISPRUDENCE.  By  HENRY  C.  CHAPMAN,  M.  D.,  Pro- 
fessor of  Institutes  of  Medicine  and  Medical  Jurisprudence  in  the  Jeffer- 
son Medical  College  of  Philadelphia,  etc  Price,  $1.50  net. 

SURGICAL  ASEPSIS.  By  CARL  BECK,  M.D.,  Surgeon  to  St.  Mark's 
Hospital  and  to  the  German  Poliklinik ;  Instructor  in  Surgery,  New  York 
Post-Graduate  Medical  School,  etc.  Price,  $1.25  net. 

MANUAL  OF  ANATOMY.  By  IRVING  S.  HAYNES,  M.D.,  Adjunct 
Professor  of  Anatomy  and  Demonstrator  of  Anatomy,  Medical  Department 
of  the  New  York  University,  etc.  Price,  $2.50  net. 

SYPHILIS  AND  THE  VENEREAL  DISEASES.  By  JAMES 
NEVINS  HYDE,  M.  D.,  Professor  of  Skin  and  Venereal  Diseases,  and 
FRANK  H.  MONTGOMERY,  M.  D.,  Lecturer  on  Dermatology  and  Genito- 
urinary Diseases  in  Rush  Medical  College,  Chicago.  Price,  $2.50  net. 

PRACTICE  OF  MEDICINE.  By  GEORGE  ROE  LOCKWOOD,  M.  D., 
Professor  of  Practice  in  the  Woman's  Medical  College  of  the  New  York 
Infirmary,  etc.  Price,  $2.50  net. 

OBSTETRICS.  By  W.  A.  NEWMAN  DORLAND,  M.  D.,  Assistant  Demon- 
strator of  Obstetrics,  University  of  Pennsylvania;  Chief  of  Gynecological 
Dispensary,  Pennsylvania  Hospital.  Price,  $2.50  net. 

DISEASES  OF  WOMEN.  By  J.  BLAND  SUTTON,  F.  R.  C.  S.,  Assistant 
Surgeon  to  the  Middlesex  Hospital,  and  Surgeon  to  the  Chelsea  Hospital 
for  Women,  London ;  and  ARTHUR  E.  GILES,  M.  D.,  B.  Sc.  Lond.,  F.  R.  C.  S. 
Edin.,  Assistant  Surgeon  to  the  Chelsea  Hospital  for  Women,  London.  436 
pages,  handsomely  illustrated.  Price,  $2.50  net. 

IN    PREPARATION. 

NERVOUS  DISEASES.  By  CHARLES  W.  BURR,  M.  D.,  Clinical  Profes- 
sor of  Nervous  Diseases,  Medico-Chirurgical  College,  Philadelphia,  etc. 

***  There  will  be  published  in  the  same  series,  at  short  intervals,  carefully  prepared  works 
on  various  subjects,  by  prominent  specialists. 

37 


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THE   REASON   WHY. 

They  are  the  advance  guard  of  "  Student's  Helps  " — that  DO  HELP;  they  are 
the  leaders  in  their  special  line,  -well  and  authoritatively  -written  by  able  rn:n, 
who,  as  teachers  in  the  large  colleges,  know  exactly  what  is  wanted  by  a  student 
preparing  for  his  examinations.  The  judgment  exercised  in  the  selection  of 
authors  is  fully  demonstrated  by  their  professional  elevation.  Chosen  from  the 
ranks  of  Demonstrators,  Quiz-masters,  and  Assistants,  most  of  them  have  be- 
come Professors  and  Lecturers  in  their  respective  colleges. 

Each  book  is  of  convenient  size  (5x7  inches),  containing  on  an  average  250 
pages,  profusely  illustrated,  and  elegantly  printed  in  clear,  readable  type,  on 
fine  paper. 

The  entire  series,  numbering  twenty  four  subjects,  has  been  kept  thoroughly 
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fifth  editions. 

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ket, none  of  them  approach  the  "  Blue  Series  of  Question  Compends;"  and 
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*$*  Any  of  these  Compends  will  be  mailed  on  receipt  of  price  (see  next 
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38 


SAUNDERS'  QUESTION-COMPEND  SERIES. 


Price,  doth,  $1.00  per  copy,  except  when  otherwise  noted, 

I.  ESSENTIALS  OF  PHYSIOLOGY.  4th  edition.  Illustrated.  Revised  and  enlarged. 
By  H.  A.  HARB,  M.  D.  (Price,  $1.00  net  ) 

a.  ESSENTIALS  OF  SURGERY.  6th  edition,  with  an  Appendix  on  Antiseptic  Sur- 
gery. 90  illustrations.  By  EDWARD  MARTIN,  M.  D. 

3.  ESSENTIALS  OF  ANATOMY.     6th  edition,  thoroughly  revised.     151  illustrations. 

By  CHARLES  B.  NANCREDE,  M.  D.     (Price,  $1.00  net.) 

4.  ESSENTIALS  OF  MEDICAL  CHEMISTRY,  ORGANIC  AND  INORGANIC. 

5th  edition,  revised,  with  an  Appendix.     By  LAWRENCE  WOLFF,  M.  D.     ($1.00  net.) 

5.  ESSENTIALS  OF  OBSTETRICS.     4th  edition,  revised  and  enlarged.      75  illustra- 

tions.    By  W.  EASTERLY  ASHTON,  M.  D. 

6.  ESSENTIALS  OF  PATHOLOGY  AND  MORBID  ANATOMY.     ?th  thousand. 

46  illustrations.     By  C.  E.  ARMAND  SEMPLE,  M.  D. 

7.  ESSENTIALS    OF    MATERIA     MEDICA,    THERAPEUTICS,    AND    PRE- 

SCRIPTION-WRITING.    5th  edition.     By  HENRY  MORRIS,  M.  D. 

8,9.  ESSENTIALS  OF  PRACTICE  OF  MEDICINE.  By  HENRY  MORRIS,  M.  D. 
An  Appendix  on  URINE  EXAMIN  ATION.  Illustrated.  By  LAWRENCE  WOLFF,  M.  D. 
3d  edition,  enlarged  by  some  300  Essential  Formulae,  selected  from  eminent  authori- 
ties, by  WM.  M.  POWELL,  M.  D.  (Double  number,  price  $2.00.) 

10.  ESSENTIALS  OF  GYNAECOLOGY.     4th  edition,  revised.     With  62  illustrations. 

By  EDWIN  B.  CRAGIN,  M.  D. 

11.  ESSENTIALS  OF  DISEASES  OF    THE  SKIN.  4th  edition,  revised  and  enlarged. 

71  letter-press  cuts  and  15  half-tone  illustrations.    By  HENRY  W.  STELWAGON,  M.D. 
(Price,  $1.00  net.) 

13.  ESSENTIALS  OF  MINOR  SURGERY,  BANDAGING,  AND  VENEREAL 
DISEASES,  ad  edition,  revised  and  enlarged.  78  illustrations.  By  EDWARD 
MARTIN,  M.  D. 

13.  ESSENTIALS  OF  LEGAL    MEDICINE,  TOXICOLOGY,  AND   HYGIENE. 

130  illustrations.     By  C.  E.   ARMAND  SEMPI.E,  M.  D. 

14.  ESSENTIALS  OF  DISEASES  OF   THE  EYE,  NOSE,  AND  THROAT.    124 

illustrations.     2d  edition,  revised.     By  EDWARD  JACKSON,  M.  D.,  and  E.  BALDWIN 
GLEASON,  M.  D. 

15.  ESSENTIALS  OF   DISEASES  OF  CHILDREN,     ad  edition.     By  WILLIAM  M. 

POWELL,  M.  D. 

16.  ESSENTIALS  OF  EXAMINATION    OF    URINE.      Colored   "VOGEL  SCALE," 

and  numerous  illustrations.      By   LAWRENCE  WOLFF,  M.  D.     (Price,  75  cents.) 

17.  ESSENTIALS  OF   DIAGNOSIS.     55   illustrations,  some  in  colors.     By  S.  SOLIS- 

COHEN,  M.  D.,  and  A.  A.  ESHNER,  M.  D.     (Price,  $1.50  net.) 

18.  ESSENTIALS  OF   PRACTICE  OF  PHARMACY.     2d  edition,  revised      By  L. 

E.  SAYRE. 

20.  ESSENTIALS  OF  BACTERIOLOGY,     sd   edition.     82   illustrations.     By  M.  V. 

BALL,  M.  D. 

21.  ESSENTIALS  OF  NERVOUS  DISEASES  AND  INSANITY.   48  illustrations. 

3d  edition,  revised.     By  JOHN  C.  SHAW,  M.  D. 

22.  ESSENTIALS  OF  MEDICAL  PHYSICS.     155  illustrations.     2d  edition,  revised 

By  FRED  J.  BKOCKWAY,  M.  D.     (Price,  $1.00  net.) 

23.  ESSENTIALS  OF  MEDICAL  ELECTRICITY.     65  illustrations.     By  DAVID  D. 

STEWART,  M.  D.,  and  EDWARD  S.  LAWRANCE,  M.  D. 

34.  ESSENTIALS  OF  DISEASES  OF  THE  EAR.  114  illustrations.  2d  edition,  re- 
vised and  enlarged.  By  E.  BALDWIN  GLEASON,  M.  D. 

39 


JUST  ISSUED. 


THE  INTERNATIONAL  TEXT-BOOK  OF  SURGERY.  In  two  vols. 
By  American  and  British  authors.  Edited  by  J.  Coi.uxs  WARREN,  M.  D., 
LL.D.,  Professor  of  Surgery,  Harvard  Medical  School,  Boston ;  Surgeon 
to  the  Massachusetts  General  Hospital;  and  A.  PEARCE  GOULD,  M.S., 
F.  R.  C.  S.,  Eng.,  Lecturer  on  Practical  Surgery  and  Teacher  of  Operative 
Surgery,  Middlesex  Hospital  Medical  School ;  Surgeon  to  the  Middlesex 
Hospital,  London,  England.  Vol.  I. — General  and  Operative  Surgery. — 
Handsome  octavo,  947  pages,  with  458  beautiful  woodcuts  and  half-tones, 
and  9  chromolithographic  plates.  Cloth,  $5-°°  ne*>  Half  Morocco,  $6.00 
net.  Sold  by  subscription.  Vol.  II. — Special  or  Regional  Surgery,  is  now 
in  press,  and  will  be  issued  on  or  before  Jan.  I,  1900. 

HEISLER'S   EMBRYOLOGY. 

A  Text-Book  of  Embryology.  By  JOHN  C.  HEISLER,  M.  D., 
Professor  of  Anatomy  in  the  Medico-Chirurgical  College,  Philadelphia. 
Octavo  volume  of  405  pages,  with  190  illustrations,  26  in  colors.  Cloth, 
$2.50  net. 

KYLE  ON  THE  NOSE  AND  THROAT. 

Diseases  of  the  Nose  and  Throat.  By  D.  BRADEN  KYLE,  M.  D., 
Clinical  Professor  of  Laryngology  and  Rhinology,  Jefferson  Medical  Col- 
lege, Philadelphia;  Consulting  Laryngologist,  Rhinologist,  and  Otologist, 
St.  Agnes'  Hospital.  Octavo  volume  of  646  pages,  with  over  150  illustra- 
tions and  6  lithographic  plates.  Cloth,  $4.00  net ;  Half  Morocco,  $5.00  net. 

PRYOR-PELVIC  INFLAMMATIONS. 

The  Treatment  of  Pelvic  Inflammations  through  the  Vagina. 

By  W.  R.  PRYOR,  M.  D.,  Professor  of  Gynecology  in  the  New  York  Poly 
clinic.  I2mo,  248  pages,  handsomely  illustrated.  Cloth,  $2.00  net. 

ABBOTT  ON  TRANSMISSIBLE   DISEASES. 

The  Hygiene  of  Transmissible  Diseases :  their  Causation, 
Modes  of  Dissemination,  and  Methods  of  Prevention.  By  A. 

C.  ABBOTT,  M.  D.,  Professor  of  Hygiene  in  the  University  of  Pennsyl- 
vania; Director  of  the  Laboratory  of  Hygiene.  Octavo  volume  of  311 
pages,  with  charts  and  maps,  and  numerous  illustrations.  Cloth,  $2.00  net. 

JACKSON— DISEASES  OF  THE   EYE. 

A  Manual  of  Diseases  of  the  Eye.  By  EDWARD  JACKSON,  A.  M., 
M.  D.,  late  Professor  of  Diseases  of  the  Eye  in  the  Philadelphia  Polyclinic 
and  College  for  Graduates  in  Medicine.  I2mo,  over  600  pages,  with  178 
illustrations  from  drawings  by  the  author. 

NANCREDE    PRINCIPLES  OF   SURGERY. 

Lectures  on  the  Principles  of  Surgery.  By  CHARLES  P..  XAN- 
CKEDE,  M.  D.,  LI,. I).,  Professor  of  Surgery  and  of  Clinical  Surgery, 
University  of  Michigan,  Ann  Arbor.  Handsome  octavo,  398  pages,  illus- 
trated. Cloth,  $2.50  net. 


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